The weapons of mass destruction-civil support team PA.

ABSTRACT: The weapons of mass destruction-civil support team (WMD-CST) physician associate/assistant (PA) is an autonomous PA who balances military and civilian roles to achieve mission success and support the safety of the US public. This article by multiple WMD-CST PAs across the nation describes the WMD-CST PA profession and how traditional PA roles continue to advance.

Acetylcholinesterase inhibitors (nerve agents) as weapons of mass destruction: History, mechanisms of action, and medical countermeasures.

Nerve agents are organophosphorus acetylcholinesterase inhibitors. Acute exposure to nerve agents can cause rapid death. In this review, we summarize the history of nerve agent development and use in warfare, the mechanisms by which these agents cause death or long-term brain damage, and the treatments for preventing death or long-term morbidity. The G-series nerve agents, tabun, sarin, soman, ethyl sarin, and cyclosarin, were developed by the Nazis. VX, the best-known of the V-series agents, was synthesized in the 1950's by a British scientist. Little is known about the development of the novichoks (the "A-series") by the former Soviet Union. Nerve agents were used for the first time in the battlefield by the Iraqi government in the Iran-Iraq War, in the 1980s. The Chemical Weapons Convention, in 1993, banned all chemical weapons production and use, yet, sarin was subsequently used in terrorist attacks in Japan and, recently, in the war in Syria. Pyridostigmine has been used as a prophylactic treatment, and bioscavengers are presently investigated as a better alternative. Atropine, along with an oxime, can prevent rapid death from the nerve agent-induced peripheral cholinergic crisis. Treatment with diazepam or midazolam for the cessation of nerve agent-induced status epilepticus cannot protect against brain damage, and, therefore, these benzodiazepines should be replaced by novel anticonvulsants and neuroprotectants. The AMPA/GluK1 receptor antagonist LY293558 (tezampanel) has shown superior antiseizure and neuroprotective efficacy against soman, particularly when administered in combination with caramiphen, an antagonist of muscarinic and NMDA receptors. This article is part of the special issue entitled 'Acetylcholinesterase Inhibitors: From Bench to Bedside to Battlefield'.

Human Casualties and War: Results of a National Epidemiologic Survey in Iran.

BACKGROUND: Limited studies have reported epidemiologic data on the impact of Iran-Iraq war. This study examines the war casualties for both combatants and civilians on Iranians at national level. METHODS: Databases of Veterans and Martyrs Affair Foundation (VMAF), Janbazan Medical and Engineering Research Center (JMERC) and Ministry of Health were used to collect the data. The prevalence of injuries for both civilians and combatants was presented. Casualties were studied based on conventional and unconventional weapons attacks (1980-2018), separately. RESULTS: The Iran-Iraq war led to 183623 lost lives, 554990 injured and 40240 captured. The mean length of captivity was 45.7 months (1 month-19 years) and 2.7% (n = 575) died in captivity. There were 1439180 war related injuries recorded in databanks, mostly affecting men (98.4%). About 1439180 injuries were recorded, most of them related to conventional weapons (938928 [65.24%]). Remaining artillery and mortar fragmentation in the body (39.5%, n = 371236), psychological disorders (15.9%, n = 228944), and exposure to chemical weapons (11%, n = 158817) were the most prevalent war-related injuries. CONCLUSION: Human casualties of the Iran-Iraq war on the Iranian side and the health care system are huge even after more than three decades.

The Toxicology Investigators Consortium Case Registry-the 2017 Annual Report.

The Toxicology Investigators Consortium (ToxIC) Case Registry was established by the American College of Medical Toxicology in 2010. The Registry collects data from participating sites with the agreement that all bedside medical toxicology consultations will be entered. The objective of this eighth annual report is to summarize the Registry's 2017 data and activity with its additional 7577 cases. Cases were identified for inclusion in this report by a query of the ToxIC database for any case entered from 1 January to 31 December 2017. Detailed data was collected from these cases and aggregated to provide information which includes demographics (e.g., age, gender, race, ethnicity), reason for medical toxicology evaluation (e.g., intentional pharmaceutical exposure, envenomation, withdrawal from a substance), agent and agent class, clinical signs and symptoms (e.g., vital sign abnormalities, organ system dysfunction), treatments and antidotes administered, fatality, and life support withdrawal data. Females were involved in 50.4% of cases. Transgender demographic information collection was initiated in 2017 to better represent the population and there were 36 cases involving transgender patients. Adults aged 19-65 were the most commonly reported age group. Non-opioid analgesics were the most commonly reported agent class, with acetaminophen again the most common agent reported. There were 93 fatalities reported in 2017. Treatment interventions were frequently reported with 30.6% receiving specific antidotal therapy. Major trends in demographics and exposure characteristics remained similar to past years' reports. While treatment interventions were commonly required, fatalities were rare.

The Biological Weapons Convention.

The Biological Weapons Convention (BWC) was the first international treaty to effectively prohibit an entire category of weapons of mass destruction. In its Preamble, the BWC clearly affirms the norm against the use of biology as a weapon by stating that such use would be 'repugnant to the conscience of mankind'. Few would dispute the strength of the norm against biological weapons, but the BWC itself, as the legal and widely accepted embodiment of this norm, requires continuous support and attention. Even after 40 years, it is not yet universal and its implementation is less than satisfactory. However, the treaty, and particularly the annual meetings of its States Parties in Geneva, have served as a venue in which all relevant stakeholders can come together to share information, experience and expertise and develop common understandings at the global level. In recent years, these meetings have been attended by a wide range of experts from national, regional and international entities from the public, private and civil sectors. International organisations such as the World Organisation for Animal Health, the Food and Agriculture Organization of the United Nations and the World Health Organization have been regular participants in the BWC meetings and their contributions are much appreciated by BWC States Parties. Cooperation and collaboration at the international level is also vital in facing the threats posed by the misuse of biological agents against humans, animals or plants. However, the recent Eighth BWC Review Conference was only able to find agreement on a small number of issues, which could put into question the role the BWC should play in countering biological threats in the future.

La Convention sur les armes biologiques (BWC) est le premier traité international à avoir interdit toute une catégorie d'armes de destruction massive. Dans le préambule de cette Convention, les États parties affirment clairement le principe de l'exclusion de la possibilité d'utiliser des agents biologiques en tant qu'armes, soulignant que la conscience de l'humanité réprouverait une telle utilisation. Si l'importance du principe d'exclusion des armes biologiques n'est guère contestée, la Convention elle-même, en tant que traduction juridique concrète et largement acceptée de ce principe nécessite une attention et un soutien continus. Quarante ans après sa signature, son application n'est toujours pas universelle et reste insatisfaisante. Toutefois, le traité et plus particulièrement les réunions des États parties à la Convention qui sont célébrées chaque année à Genève offrent à l'ensemble des parties concernées l'occasion d'échanger et de mettre en commun leurs informations, leur expérience et leur expertise afin de contribuer à une entente sur ces questions à l'échelle mondiale. Depuis quelques années, ces réunions ont accueilli de nombreux experts d'horizons variés, issus d'organismes nationaux, régionaux et internationaux des secteurs tant public que privé mais aussi de la société civile. Diverses organisations, dont l'Organisation mondiale de la santé animale, l'Organisation des Nations Unies pour l'alimentation et l'agriculture et l'Organisation mondiale de la santé participent régulièrement aux réunions de la Convention et leurs contributions sont fortement appréciées par les États parties à la Convention. La mise en place d'une coopération et d'une collaboration à l'échelle internationale est également essentielle pour faire face aux menaces posées par l'utilisation abusive d'agents biologiques contre les humains, les animaux ou les plantes. Néanmoins, lors de la huitième Conférence d'examen des États parties à la Convention qui s'est tenue récemment, ceux-ci n'ont pu s'accorder que sur un nombre limité de questions, ce qui pourrait remettre en cause le rôle déterminant de la Convention pour contrecarrer les menaces biologiques à l'avenir.

La Convención sobre las Armas Biológicas fue el primer tratado internacional por el que toda una categoría de armas de destrucción masiva quedó efectivamente prohibida. En su Preámbulo queda claramente fijado el principio según el cual todo uso de la biología como arma es algo que «repugna a la conciencia de la humanidad¼. Aunque pocos tendrían algo que objetar a la autoridad de un principio que condena el uso de armas biológicas, la Convención en sí misma, como materialización jurídica y ampliamente aceptada de tal principio, exige atención y apoyo permanentes. Aun después de 40 años, sigue sin revestir carácter universal, y su aplicación dista de ser satisfactoria. Pese a todo el tratado, y en especial las reuniones anuales que se celebran en Ginebra como parte de su aplicación, han servido de cauce para que todas las partes interesadas puedan reunirse, intercambiar información, experiencias y conocimientos técnicos y encontrar un terreno de entendimiento común a escala mundial. En los últimos años, a esas reuniones han acudido muy diversos expertos de entidades nacionales, regionales e internacionales de los sectores público y privado, así como de la sociedad civil. Organizaciones internacionales como la Organización Mundial de Sanidad Animal, la Organización de las Naciones Unidas para la Alimentación y la Agricultura y la Organización Mundial de la Salud han participado regularmente en las reuniones de los Estados partes en la Convención, que han acogido muy positivamente sus aportaciones. La cooperación y la colaboración internacionales también son imprescindibles para hacer frente a la amenaza derivada del uso indebido de agentes biológicos contra personas, animales o plantas. En la Octava Conferencia de Examen de la Convención, sin embargo, que tuvo lugar en fechas recientes, solo hubo acuerdo en torno a muy contadas cuestiones, lo que podría poner en entredicho la función que la Convención debe cumplir en el futuro para conjurar las amenazas biológicas.

An assessment of Chemical, Biological, Radiologic, Nuclear, and Explosive preparedness among emergency department healthcare providers in an inner city emergency department.

INTRODUCTION: Emergency healthcare providers are required to care for victims of Chemical, Biological, Radiologic, Nuclear, and Explosive (CBRNE) agents. However, US emergency departments are often ill prepared to manage CBRNE casualties. Most providers lack adequate knowledge or experience in the areas of patient decontamination, hospital-specific disaster protocols, interagency familiarization, and available supply of necessary medical equipment and medications. This study evaluated the CBRNE preparedness of physicians, nurses, and midlevel providers in an urban tertiary care emergency department. METHODS: This retrospective observational survey study used a previously constructed questionnaire instrument. A total of 205 e-mail invitations were sent to 191 eligible providers through an online survey distribution tool (Survey Monkey®). Respondents were enrolled from February 1, 2014 to March 15, 2014. Simple frequencies of correct answers were used to determine the level of preparedness of each group. Cronbach's coefficient α was used to validate the precision of the study instrument. Finally, validity coefficients and analysis of variance ANOVA were used to determine the strength of correlation between demographic variables, as well as the variation between individual responses. RESULTS: Fifty-nine providers responded to the questionnaire (31.14 percent response rate). The overall frequency of correct answers was 66.26 percent, indicating a relatively poor level of CBRNE preparedness. The study instrument lacked precision and reliability (coefficient α 0.4050). Significant correlations were found between the frequency of correct answers and the respondents' gender, practice experience, and previous experience with a CBRNE incident. Significant variance exists between how providers believe casualties should be decontaminated, which drugs should be administered, and the interpretation of facility-specific protocols. CONCLUSIONS: Emergency care providers are inadequately prepared to manage CBRNE incidents. Furthermore, a valid and precise instrument capable of measuring preparedness needs to be developed. Standardized educational curriculums that consider healthcare providers' genders, occupations, and experience levels may assist in closing the knowledge gaps between providers and reinforce emergency departments' CBRNE preparedness.

Just-in-time learning is effective in helping first responders manage weapons of mass destruction events.

BACKGROUND: Chemical, biologic, radiologic, nuclear, and explosive (CBRNE) incidents require specialized training. The low frequency of these events leads to significant skill decay among first responders. To address skill decay and lack of experience with these high-impact events, educational modules were developed for mobile devices to provide just-in-time training to first responders en route to a CBRNE event. This study assessed the efficacy and usability of the mobile training. METHODS: Ninety first responders were randomized to a control or an intervention group. All participants completed a pretest to measure knowledge of CBRNE topics. The intervention group then viewed personal protective equipment and weapons of mass destruction field management videos as an overview. Both groups were briefed on a disaster scenario (chemical nerve agent, radiologic, or explosives) requiring them to triage, assess, and manage a patient. Intervention group participants watched a mobile training video corresponding to the scenario. The control group did not receive prescenario video training. Observers rated participant performance in each scenario. After completing the scenarios, all participants answered a cognitive posttest. Those in the intervention group also answered a questionnaire on their impressions of the training. RESULTS: The intervention group outperformed the control group in the explosives and chemical nerve agent scenarios; the differences were statistically significant (explosives, mean of 26.32 for intervention and 22.85 for control, p < 0.01; nerve agent, mean of 23.14 for intervention and 16.61 for control, p < 0.01). There was no statistically significant difference between the groups in the radiologic scenario (mean, 12.7 for intervention and 11.8 for control; p = 0.51). The change in pretest to posttest cognitive scores was significantly higher in the intervention group than in the control group (t = 3.28, p < 0.05). CONCLUSION: Mobile just-in-time training improved first-responder knowledge of CBRNE events and is an effective tool in helping first responders manage simulated explosive and chemical agent scenarios. LEVEL OF EVIDENCE: Therapeutic/care management study, level II.

The contribution of on-call, volunteer first responders to mass-casualty terrorist attacks in Israel.

OBJECTIVE: To describe the contributions of on-call, volunteer first responders to mass-casualty terrorist attacks in Israel during the Second Intifada. DESIGN: Descriptive study evaluating data obtained from postevent debriefings after 15 terrorist attacks in Israel between 2001 and 2004. RESULTS: An average of 7.9 deaths (median 7.0, interquartile range [IQR] 2.5-12.5) and 53.8 injuries (median 50.0, IQR 34.0-62.0) occurred in each of these attacks. The average number of volunteers responding to each event was 50.3 (median 43.0, IQR 27.5-55.5). The volunteers were involved in extricating victims from imminent danger, and performing emergent tasks such as bag-valve ventilation, tourniquet application, and intravenous line insertion. They were also integral to the rapid evacuation of casualties from the scene. CONCLUSION: On-call, volunteer first responders are an integral part of Israel's emergency medical response to mass-casualty terrorist attacks. This system may be used as a model for the development of similar services worldwide.

Recent advances in medical device triage technologies for chemical, biological, radiological, and nuclear events.

In 2010, the US Food and Drug Administration (Silver Spring, Maryland USA) created the Medical Countermeasures Initiative with the mission of development and promoting medical countermeasures that would be needed to protect the nation from identified, high-priority chemical, biological, radiological, or nuclear (CBRN) threats and emerging infectious diseases. The aim of this review was to promote regulatory science research of medical devices and to analyze how the devices can be employed in different CBRN scenarios. Triage in CBRN scenarios presents unique challenges for first responders because the effects of CBRN agents and the clinical presentations of casualties at each triage stage can vary. The uniqueness of a CBRN event can render standard patient monitoring medical device and conventional triage algorithms ineffective. Despite the challenges, there have been recent advances in CBRN triage technology that include: novel technologies; mobile medical applications ("medical apps") for CBRN disasters; electronic triage tags, such as eTriage; diagnostic field devices, such as the Joint Biological Agent Identification System; and decision support systems, such as the Chemical Hazards Emergency Medical Management Intelligent Syndromes Tool (CHEMM-IST). Further research and medical device validation can help to advance prehospital triage technology for CBRN events.

Armies of pestilence: CNS infections as potential weapons of mass destruction.

Infectious agents have been investigated, developed, and used by both governments and terrorist groups as weapons of mass destruction. CNS infections, though traditionally considered less often than respiratory diseases in this scenario, may be very important. Viruses responsible for encephalitides can be highly infectious in aerosol form. CNS involvement in anthrax is ominous but should change treatment. Brucellosis, plague, Q fever, and other bacteria can uncommonly manifest with meningoencephalitis and other findings. Emerging diseases may also pose threats. We review infectious agents of particular concern for purposes of biowarfare with respect to CNS manifestations and imaging features.

Moral bioenhancement and the utilitarian catastrophe.

This article challenges recent calls for moral bioenhancement-the use of biomedical means, including pharmacological and genetic methods, to increase the moral value of our actions or characters. It responds to those who take a practical interest in moral bioenhancement. I argue that moral bioenhancement is unlikely to be a good response to the extinction threats of climate change and weapons of mass destruction. Rather than alleviating those problems, it is likely to aggravate them. We should expect biomedical means to generate piecemeal enhancements of human morality. These predictably strengthen some contributors to moral judgment while leaving others comparatively unaffected. This unbalanced enhancement differs from the manner of improvement that typically results from sustained reflection. It is likely to make its subjects worse rather than better at moral reasoning.

Hazmat update.

EMS responders to hazmat incidents face significant challenges; however, integration of medical care providers into the planning process for hazmat incidents can facilitate a more efficient response. The competencies found in NFPA 473 provide thorough guidance for EMS professionals during planning, preparation and response to hazmat/ WMD incidents. JEMS

CBRNE TC3: A Hybrid Approach to Casualty Care in the CBRNE Environment.

The implementation of Tactical Combat Casualty Care (TCCC) guidelines for the Operation Enduring Freedom and Operation Iraqi Freedom contingency operations has dramatically reduced preventable combat deaths. A study of these principles and their application to medical treatment in the chemical, biological, radiological, nuclear, and high-yield explosives (CBRNE), weapons of mass destruction (WMD) environment is presented as a potential readiness and force multiplier for units engaged in this area of operations. Preparing medical operators for support of WMD sampling and mitigation missions requires extensive preventive medicine and post-exposure and downrange trauma threat preparedness. Training and equipping CBRN operators with treatment skills and appropriate interventional material requires pre-implementation planning specific to WMD threats (e.g., anthrax, radiation, organophosphates, and contaminated trauma). A scenario-based study reveals the tactics, techniques, and procedures for training, resourcing, and fielding the CBRN operator of the future.