Preparing your anesthesia department for radiologic, biologic, and chemical attack

Preparing Your Anesthesia Department for Radiologic, Biologic, and Chemical Attack Clifford Gevirtz

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nlike conventional warfare, asymmetric warfare (also known as terrorism) may start without announcement or heralding event. The start may be an increased number of hospital admissions for fever, shortness of breath, unexplained rashes, mucosal or dermal irritations, or generalized weakness, or an increased number of consultations for airway management because of bulbar palsies. There may be unusual temporal or geographic clustering of illnesses (eg, patients who attended the same ball game, live in the same part of town, or who all work at the same hospital). Because of this lack of warning time, it is incumbent upon clinical directors to prepare their departments to meet the sequelae of an attack that may occur at any time. However, the nature and timing of a future strike is extremely unpredictable, and a flexible plan is essential. In the subway attack in Japan, it was initially unclear what had transpired; response and reserve in depth is therefore probably the best defense. Fortunately, the attack was poorly executed with a nonpersistent nerve agent. Ventilatory support was given at the scene and during transport, so causalities were limited to 4 dead, although scores were injured. What would have happened if an experienced terrorist (eg, a veteran from a chemical weapons unit) had been involved? Clearly, the death toll could have been much higher. In a recent police raid on terrorists and their hostages in a Moscow theater, there was no on-scene ventilatory support, and the victims were transported without assisted ventilation 1 mile away to hospitals where it was not certain that the physicians were fully informed about what agent had been used by the rescuers to immobilize the gunmen. The mortality

From the Bronx VA Medical Center and the Mt. Sinai School of Medicine, New York, NY. Address reprint requests to Clifford Gevirtz, MD, Bronx VA Medical Center, 130 West Kingsbridge Road, Bronx, NY 10468. © 2003 Elsevier Inc. All rights reserved. 0277-0326/03/2204-0000$30.00/0 doi:10.1053/S0277-0326(03)00045-X

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rate was much higher. Proper planning and preparation can markedly change the outcome of such events. We should consider the awful but very real probability of an attack and how to prepare our hospitals and operating rooms. Planning starts with a candid assessment of available resources and capabilities. Effective preparation also requires the running of multiple detailed drills and candid critiquing of the results. Once a quarter drills that meet Joint Commission on Accreditation of Healthcare Organizations requirements will not produce the learned responses necessary to deal effectively with a sudden attack. INITIAL PREPARATION

In a biologic attack, such as with anthrax, the ability to manage a large number of ventilated patients in a critical care setting almost certainly will require redeployment of staff and materials from the operating room. The depth of antibiotic supply and the number of ventilators and associated support materials must be determined to make an informed judgment about the absolute maximum number of patients that can be effectively managed. In preparing for an attack, the concept of “just in time” inventory is the antithesis of “reserve in depth,” which is required to effectively deal with the situation. Questions to be asked include the following: ● ● ●

What is the total number of endotracheal tubes available? How many ventilators and anesthesia machines are available? How many vials of atropine are in reserve?

These “excess” supplies are obviously not revenue producing and lower hospital profitability. The Center for Disease Control (CDC) maintains “push packs” that contain tens of thousands of doses of broad-spectrum antibiotics and other emergency drugs for dealing with attacks from weapons of mass destruction. Although these

Seminars in Anesthesia, Perioperative Medicine and Pain, Vol 22, No 4 (December), 2003: pp 278-285

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Table 1. Nerve Gas Management

Patients Age Infant (less than 2 years) Child (2-10 years old) Adolesecent-Adult (⬎10 years old)

Mild Symptoms: Localized sweating Shortness of Breath GI symptoms: nausea, vomiting, diarrhea Muscle fasciculations Generalized weakness

Severe Symptoms: Apnea Seizures Flaccid paralysis Unconsciousness

Atropine 0.05 mg/kg IM or 0.02 mg/kg IV 2-PAM 15 mg/kg IV slowly Atropine 1 mg IM 2-PAM 15 mg/kg IV slowly Atropine 2 mg IM 2-Pam 15 mg/kg IV slowly (max. dose is 1 Gram)

Atropine 0.1mg/kg IM or 0.02 mg/kg IV 2-PAM 15 mg/kg IV slowly Atropine 2 mg/kg IM 2-PAM 15 mg/kg IV slowly Atropine 4 mg/kg IM 2-PAM 15 mg/kg IV slowly (max. dose is 1 Gram)

Notes: Use diazepam for seizure control (0.2-0.5 mg IV ⬍5 yo; 1 mg IV for children ⬎5 yo; 5 mg for adults). Repeat atropine every 5 to 10 minutes until secretions have diminished and dyspnea relieved (for infants, use 2 mg IM or 1 mg IV). N.B. These very large doses are NOT misprints. It may take extremely large doses to effectively treat exposure.

packs are readily transported by cargo aircraft and can be delivered anywhere in the United States within 12 hours, first-response hospitals may have to support large numbers of patients before the arrival of these supplies. In a chemical attack, the treatment of life-threatening symptoms takes precedence over identification of the agent involved. Here, the anesthesiologist has critical experience because, for example, manipulation of the neuromuscular junction is a part of our everyday practice. Nerve agents denature the acetylcholinesterase enzyme, and the patient has incomplete neuromuscular blockade with an excess of acetylcholine at the motor end plate.1-3 The process of denaturation takes place in 2 steps: (1) where there is still the potential for reversibility of the enzyme with 2-PAM (Pralidoxime–Protopam®); (2) as the enzyme is “aged” and the damage becomes irreversible. Other adverse effects, including diarrhea, vomiting, excessive salivation, and lacrimation, are caused by an excess of acetylcholine. A suggested regimen for treating nerve-gas attack is presented in Table 1. The two key therapeutic agents to be used are 2-PAM and atropine. 2-PAM is a peripheral acetylcholinesterase reactivator for certain phosphoryl– enzyme complexes. The reason only a single dose of 2-PAM is utilized is that if the enzyme has already aged, then the patient will not show any signs of improvement, but if reversibility is still possible the patient will get noticeably better

quickly. If the damage has progressed to irreversible aging, then additional 2-PAM will not correct the problem. Although atropine is the drug of choice for dealing with cholingeneric excess, other members of the class, eg, scopolamine and glycopyrolate, can be utilized when atropine supplies are exhausted. Situation Readiness and Report

In responding to a chemical attack, a key issue is awareness of the distance between the emergency site and the hospital. Knowledge of wind directions is critical (downwind or upwind). The nerve gases (eg, GB, sarin) and blister agents are all heavier than air and will sink to just above ground surface. VX, which is in liquid form and is sprayed as a Table 2. Personal Readiness 1. Keep several changes of clothes in your locker. 2. Personal toiletries: Toothbrush/toothpaste/mouthwash/ soap/shampoo/comb etc. 3. If you are taking any medications keep an extra 30-day supply 4. The emergency backup list should be kept discreetly taped within every anesthesia machine as well as in your locker. 5. Cell phone with back-up battery 6. Flash light with a set of back up batteries 7. Long shelf life food such as foils of tuna or beef jerky. (While you are unlikely to run out of food in a hospital, long stretches without proper relief may occur.)

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mist of droplets, will also fall rapidly onto surfaces. One thing to keep in mind when treating patients who have been exposed to VX is that VX is persistent, and droplets on clothing underneath the patient may be exposed when the patient is rolled over, causing problems to develop in healthcare personnel attending the patient if they are not wearing the correct isolation equipment. One must also ascertain the direction in which the agent is moving, ie, is the facility in the hot zone, or is it far enough removed not to have to deal with the possibility of direct gas intake? If the answer to these questions is not readily available, then one must consider how to isolate the operating room from the heating, ventilation, and air conditioning (HVAC) system. The first step in preparation is determining how the facility and the operating room are ventilated. Can the anesthesiologist isolate the operating room suite by him/herself in an emergency situation? Does the emergency room share the HVAC circuit with the operating room? If so, it is important to note that if the emergency room is subject to airborne contamination, then it may spread rapidly to the operating room. The ideal situation is to develop two separate dedicated ventilation systems. Similarly, one should question if the operating room is on the same circuit as the admissions area. Here, patients who are still ambulatory but contaminated could spread the chemical. Another key step is to identify the location of the HVAC master controls and familiarize the staff with key switches. The scavenger system must also be disabled. A quality-improvement exercise includes a drill on shutting down the ventilation system and ensuring that everyone knows how to do it. In the operating room itself, all staff should know how to isolate individual room ventilation systems. Preparing the Physical Plant for a Terrorist Attack

Getting to know a physical plant may be best handled by conducting a walk-through inspection of the hospital and its systems, including the HVAC, fire protection, and life-safety systems, with the hospital engineer. A partial list of items to consider during the building walk-through includes the following:4 ● ● ●

Which filtration systems are in place? What are their efficiencies? If there were an airborne release of anthrax

● ● ● ● ● ●

spores, then would the filters protect the facility? Do all of the dampers close? How often are they inspected? Are the variable air volume boxes all working? Is there a centralized control that governs the HVAC system? Is there any back-up of this system? Is there a simple manual that explains how it functions should the engineer be unavailable?

Recommendations for preparedness can be divided into 4 basic groups: ● ● ● ●

Things not to do Increasing the physical security of the hospital Ventilation and filtration Maintenance, administration, and training

Things Not to Do More than anything else, hospitals should ensure that any actions taken do not have a detrimental effect on the building systems (HVAC, fire protection, life safety, etc.) or the building occupants under normal operating conditions. Efforts to protect the building from an attack could have adverse effects on the indoor environmental quality. There should be an understanding of how the hospitals’ systems operate and an assessment made of the impact of security measures on those systems before undertaking any changes. Do not permanently seal outdoor air intakes. Buildings require a steady supply of outdoor air. This supply should be maintained during normal building operations. Closing off the outdoor air supply vents will adversely affect the building occupants and likely result in a marked decrease in indoor environmental quality and an increase in indoor environmental quality complaints. Do not modify the hvac system without first understanding the effects on the hospital. If there is uncertainty about the effects of a proposed modification, then a qualified professional should be consulted. Do not interfere with fire protection and life safety systems. These systems provide protection in the case of fire or other types of events. They should not be altered without guidance from a professional specifically qualified in fire protection and life safety systems.

PREPARING FOR RADIOLOGIC, BIOLOGIC, AND CHEMICAL ATTACK Increasing Physical Security Preventing terrorist access to the hospital requires a review of the physical security of entryways, storage areas, the roof, and mechanical areas, as well as secure access to the outdoor air intakes of the HVAC system. Some physical security measures, such as locking doors, are low cost and will not inconvenience the users of the hospital. Care should be taken that access still can be obtained to the outside in the case of fire. These types of measures can be quickly and easily implemented in most hospitals. Other physical security measures, such as increased security personnel or package X-ray equipment, are much more costly or may inconvenience users substantially. These measures should be implemented when merited only after consideration of the threat and consequences of a terrorist attack, eg, rural hospitals are less likely to be attacked than ones situated next to a national monument. Prevent access to outdoor air intakes. One of the most important steps in protecting a building’s indoor environment is the security of the outdoor air intakes. These should be fenced off and kept under observation. Ventilation and Filtration The air intake and filtration systems are designed to exchange the total volume of air in the hospital several times per day— either heating or cooling and humidifying it. The key factors to identify are the means to shut it down quickly in an emergency and the degree of air filtration that it provides. Does it filter out most pollen, an excellent marker for spores? Maintenance, Administration, and Training It is very easy to become involved in the immediate aftermath of a terrorist event and start organizing and conducting drills, but because the interval between events can be months or years it takes a great deal of persistence to maintain these activities and the necessary levels of training and preparedness. A financial analysis might indicate that cannibalization of the reserve for a month could keep a budget on track. Such an action might be a tempting option. Keeping a record of drills, including call-back exercises, and how well the participants have performed should be reviewed and critiqued. Only in this way

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will there be any improvement. A letter home from a young soldier during the Civil War best typifies the degree of automatocity required. “We drilled immediately after breakfast, then took a quick march around the post and drilled some more, then more drill, still more drill, a light lunch, then drill, more drill, another run and then drilled again. We broke for dinner and then one last drill before the sunset. We spent most of May trampling the countryside do exactly nothing but drill.” Some months later, that unit found itself in the middle of the line in Gettysburg and was assaulted by withering fire, but the men from Maine knew their business and held that day. Such is the value of drill. OTHER TOXIC GASES: GENERAL CHARACTERISTICS

Other gases with the potential for use by terrorists tend to interfere with 1 or more of the 4 phases of oxygen delivery: uptake, diffusion, transport, and utilization.6 Simple asphyxiants displace oxygen from the inspired gas mixture, resulting in diminished uptake. Pulmonary irritants cause noncardiogenic pulmonary edema and impair oxygen diffusion across the alveolar membrane. Chemical asphyxiants affect either the transport or utilization of oxygen at the mitochondrial level to poison the cell. Simple Asphyxiants

Simple asphyxiants displace oxygen from air (carbon dioxide, nitrogen, hydrogen, methane, propane) within a closed space or, when released in massive quantities, move as a cloud. When the concentration of any of these gases increases, by definition, the fraction of inspired oxygen (FiO2) decreases. At a FiO2 of less than 16%, air hunger, tachypnea, and changes in the level of consciousness occur rapidly. At a FiO2 of less than 10%, loss of consciousness, seizures, and/or vomiting occur. The most effective treatment is restoration of a higher inspired oxygen, with supplemental oxygen and discontinuation of exposure to the hypoxic mixture. The extent of the damage depends on the duration and severity of the exposure. When faced with an overwhelming number of patients, it may be necessary to intubate, ventilate with a high FiO2, and then move on to the next patient. If all the ventilators are in use, then anesthesia machines can be employed, as can AMBU® bags manned by teams of medical students or other per-

282 sonnel. The higher the initial concentration of oxygen and the sooner therapy is started, then the better the outcome Irritant Gases

Highly water-soluble agents react with water in the upper respiratory tract to produce immediate irritation and edema. Ammonia, used as an industrial refrigerant, is prototypical. Chloramine, another simple chemical agent, is created when household bleach and ammonia are mixed together. Warning symptoms of exposure include eye irritation and peri-orbital edema, burning in the throat, and constriction of the upper airway. Treatment is aimed at supplying supplemental oxygen, discontinuing the exposure, and monitoring the pulmonary status with a pulse oximetry. Chlorine, which appears as a bright yellow cloud hugging the ground (at least as described by World War I veterans), reacts with exhaled water vapor in the upper airways to produce hydrochloric acid, which in turn causes burning of the conjunctiva, throat, and the bronchial tree. In higher concentrations, it can produce bronchospasm, injury to the alveoli, and lead to pulmonary edema. Treatment involves supplying supplemental oxygen, treating the bronchospasm, and monitoring the pulmonary status by pulse oximetry. Prophylactic intubation with addition of positive end expiratory pressure may be required. Phosgene, another agent used in World War I, is prototypical of the slightly water-soluble gases. At concentrations as low as 25 ppm, it can be fatal after even brief exposure. It produces minimal warning symptoms (smells like fresh-cut grass) consisting of mild irritation of the eyes and upper airways. Because it slowly hydrolyzes to hydrochloric acid, it is inhaled down to the level of the alveoli, which results in the delayed onset of pulmonary edema. Treatment is supplemental oxygen, including pulmonary monitoring, intubation, and ventilation with positive end expiratory pressure as indicated to maintain oxygen saturation. In crisis conditions, it may not be possible to obtain frequent chest X-rays and serial blood gas analysis. Clinical judgment must guide therapy rather than technology. Chemical Asphyxiants

Chemical asphyxiants react in the body to interrupt either the delivery or utilization of oxygen. Carbon monoxide binds to hemoglobin, creating

CLIFFORD GEVIRTZ carboxyhemoglobin, and has 250 to 270 times the affinity of oxygen, making the latter incapable of binding and transporting oxygen. The nitrites convert the ferrous iron atom in the hemoglobin molecule to the ferric state or methemoglobin, which can neither bind nor transport oxygen. Both carboxyhemoglobin and methemoglobin can be measured by co-oximetry on an arterial blood gas analyzer, and both are treated with high concentrations of oxygen. Hyperbaric oxygen can be used for carbon monoxide exposures to patients with altered levels of consciousness and neurologic findings but, of course, in mass-causality situations there will not be enough room in the available chambers (most chambers are of 1- or 2-person design). Methemoglobinemia can be treated with methylene blue, which acts as an electron donor, and converts ferric iron back to the ferrous state. Patients with methemoglobin levels in excess of 30% should be treated with 1 mg/kg methylene blue as a 10% solution intravenously. Other chemical asphyxiants can interfere with the electron transport chain in the mitochondria. The most common example is hydrogen cyanide. By binding to cytochrome oxidase, aerobic metabolism is halted and intracellular acidosis results almost immediately. Symptoms include headache, alteration of consciousness, seizures, and severe acidosis. The cyanide antidote kit contains 3 components: pearls of amyl nitrite, an ampoule of sodium nitrite, and an ampoule of sodium thiosulfate. Either the inhaled amyl nitrite, from a crushed pearl, or the intravenous sodium nitrite will induce methemoglobinemia. Both cyanide and sulfide will in turn bind with greater affinity to methemoglobin than to the cytochrome oxidase enzyme complex, forming either cyanomethemoglobin or sulfmethemoglobin. The cyanomethemoglobin thus produced is detoxified in the liver by the enzyme rhodanase. Sodium thiosulfate, the third component of the cyanide antidote kit, will stimulate the conversion of cyanide to sodium thiocyanate, which is renally excreted. The sodium thiosulfate component is indicated only for suspected cyanide exposure, whereas the nitrite components can be used with sulfide or cyanide exposure. RADIOLOGIC ATTACK

In a radiological attack, a dirty bomb containing a radioactive source is wrapped around a conventional explosive. The issue is one of effective de-

PREPARING FOR RADIOLOGIC, BIOLOGIC, AND CHEMICAL ATTACK contamination and immediate surgical treatment of any shrapnel wounds.7,8 The key points to remember are that removing the clothing from an externally contaminated patient removes most of the contamination. The clothing should be cut off the patient, placed in plastic bags, and segregated for examination by the radiation safety officer and possibly by law enforcement at a designated decontamination area with shower facilities. The patient is then showered with water and scrubbed of obvious dirt or dust. S/he may need to be cocooned in sheets and transported to the operating room for any necessary surgical interventions. Internal contamination when the patient ingests, inhales, or otherwise absorbs radioactive material rarely presents a hazard to healthcare workers. The personal protective gear used when treating infectious patients (ie, shoe covers, disposable gown, head cover, eye protection (shield) N95 mask, and gloves) are usually all that is necessary. The two exposure-limiting strategies are to minimize the time near the radiation source and to maximize the distance from the radiation source, which is best accomplished by using lead aprons, thyroid shields, and lead glass shields strategically placed near the operating field and the anesthesia machine. The dose of radiation received varies with the inverse square rule, ie, every 1 m away from the patient decreases the dose by the square root of the distance. At 3 m, the dose is one ninth that at 1 m. Radiation monitor badges should be routine for all healthcare workers, including residents, medical students, and other personnel who may be on rotation at a site. Although they are not of immediate use in detecting a radioactive incident, analyses will be helpful in determining the outcome should there be any radiation sickness from exposure to shrapnel or dust. The most likely dirty bomb would contain a small or medium amount of explosives (10-50 pounds [4.5-23 kg] of TNT, eg) with a small amount of low-level radioactive material (eg, a small amount of cesium-137 or cobalt-60 from a university lab). This sort of bomb is not very destructive. Most likely, any immediate deaths (and all property damage) would be from the explosive itself rather than from the radiation. The explosive acts as a dispersing force for the radioactive material. A radioactive dust cloud would extend well beyond the explosion site, possibly covering several square miles. Bombs con-

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taining radioactive waste from nuclear power plants or portable nuclear generators would inflict more damage, but terrorists would be less likely to use them because they are much harder to transport and to handle. The terrorists could die from exposure while building and transporting the bomb. Some experts believe, however, that extremists would be willing to die while preparing a bomb. If local inhabitants of a blast area were able to get rid of contaminated clothes, shower, and evacuate within 1 day of a small or medium blast, there would probably be no consequences. The bomb would boost radiation levels above the normal “safe” level, but not significantly. In the short term, the human body can handle this increased exposure. People very close to the blast could conceivably suffer radiation sickness and might require hospital care. The main concern would be prolonged exposure. Many radioactive isotopes bind with other materials—including concrete and metal— extremely well, making it nearly impossible to completely remove the material without demolishing all contaminated structures. Clean-up crews could wash away a lot of the radioactive material, but a small amount would probably remain in the city for many years, even decades. Anybody living there would be exposed regularly to this radiation, which could conceivably cause cancer. There is no precedent for a dirty bomb attack, but we can learn from other incidents of radioactive contamination. Citizens of Nagasaki and Hiroshima were exposed to a much larger amount of radioactive material, from an actual nuclear blast, and today both cities are considered completely safe for habitation. On the other hand, there are still areas around Chernobyl that are considered unsafe because of high radioactivity from long half-life elements. Most experts agree that a dirty bomb would be more of a disruptive weapon than a destructive weapon. The news of radioactive contamination would probably cause widespread panic, and the rush to evacuate the targeted city could actually cause more damage than the bomb itself. This is the precise reason dirty bombs are such an attractive weapon to terrorists. Their main goal is to cause panic and inspire terror, which are 2 things a dirty bomb would certainly accomplish. The Office of Homeland Security would help guide the local authorities on the establishment of isolation zones based on 2 important pieces of information—the hazards present and the results of air monitoring.

284 The initial isolation zones would have a large diameter. This initial zone would be decreased as the event evolved, based on radioactivity monitoring conducted by NEST (Nuclear Emergency Support Team). A hospital within the initial isolation zone would have to choose between staying in place (shutting down the ventilation system, closing and sealing all doors and windows, and sheltering in the basement or in the inner corridors) and evacuation. The decision would be made based on the availability of transport and the number of staff and critically ill patients. The greatest probability would be sheltering in place until organized external help arrives. Although it may seem trite to say, success in this situation will be marked by those who remain calm and lead, and not by those who panic and run. Typically, the 3 initial zones are 1,000 feet in diameter (3 typical city blocks) for radioactive materials dispersed by a small “dirty” bomb, up to 1 mile for larger bombs or explosive materials, and over 7 miles for sarin or other nerve-gas agents. Learning where the incident occurred is paramount to determining the extent of the isolation zone and whether the hospital lies within those boundaries. Attention to personnel readiness is necessary to effectively deal with sheltering in place or quarantine. Table 1 shows a brief list of supplies that should be kept by every member of the department. Although staff are unlikely to run out of food in the hospital, there may be very long stretches without regular relief. PAIN MANAGEMENT IN MASS-CASUALTY SITUATIONS

There may come a point in any crisis where the hospital is overwhelmed and palliation rather than cure becomes a prominent issue. Here, the painmanagement specialist may be called upon to minister to the dying in less than ideal conditions, and ingenuity may be required to bring comfort. Clearly, the concept of administering a drug, evaluating its effect, and monitoring for further complications or redosing may not be possible. It is suggested that absent a chart or other clear documentation, the drug and dose and time be written directly on the patient’s forehead or arm with a pen or magic marker. Usually, there will be a triage tag tied to an extremity where this information can be recorded, but in mass-causality situations this may not occur. Opiates and benzo-

CLIFFORD GEVIRTZ diazepines remain the first line of therapy, but when these are depleted other unusual approaches, including the use of dextromorphan, clonidine, and transdermal fentanyl, can be employed. Dextromorphan is an N-methyl-D-aspartate receptor agonist that will potentiate the analgesia produced by small amounts of opiates. It is commonly available in over-thecounter cough syrup. Thirty mg orally administered will reduce by 50% the amount of opiates required. Similarly, clonidine, either orally or transdermally, will reduce opiate requirements. Finally, although FDA labeling specifically warns against the use of transdermal fentanyl for acute pain situations, in a crisis where other opiates are in short supply, the application of transdermal fentanyl to an area of skin that has been first rubbed vigorously with alcohol pads will allow for rapid uptake of fentanyl and, when transdermal clonidine is added to the area, potent analgesia will be obtained.8 The classic drug to provide both analgesia and anesthesia in the field without supplemental oxygen is ketamine. As a sole analgesic, it is administered at a dosage of 0.5 to 2 mg/kg intramuscularly every 30 minutes. It should be noted that if the patient is already suffering from exposure to nerve agents, then the amount of salivation might actually increase. The major advantage is that this drug will not lower blood pressure unless the patient is at the end stage of hemodynamic shock. CONCLUSIONS

Preparing the anesthesia department for action in a crisis starts well before any actual terror attack. It should begin with a thorough inventory of supplies and an assessment of capabilities and it should continue with training designed to simulate various terror scenarios. Each member of the department needs to prepare by familiarizing him/ herself with the agents and devices that may be used in chemical and radiologic attacks. Qualityimprovement exercises that replicate various disaster drills should be run frequently and then critiqued for deficiencies. As one of my professors once said, “Proper prior preparation prevents pitifully poor performance.” Only by drilling repeatedly will the challenge of a terror attack be met. REFERENCES 1. Holloway HC, Norwood AE, Fullerton CS, et al: www. cs.amedd.army.mil/qmo

PREPARING FOR RADIOLOGIC, BIOLOGIC, AND CHEMICAL ATTACK 2. Holloway HC, Norwood AE, Fullerton SC, et al: www. nbc-med.org 3. Holloway HC, Norwood AE, Fullerton CS, et al: Biological terrorism: preparing to meet the threat. JAMA 278:428430, 1997 4. “Guidance for Protecting Building Environments from Airborne Chemical, Biological, or Radiological Attack.” DHHS NIOSH Pub No. 2002-139, May 2002 5. Franz DR, Juhrling PB, Friedlander AM, et al: Clinical

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recognition and management of patients exposed to biological warfare agents. JAMA 279:399-411, 1997 6. Fredrick R, Sidell WC, Iii P, et al: Janes’s Chem Bio Handbook, 2nd ed. Alexandra, VA, Jane’s Information Group, 2002 7. Radiological Dispersal Devices (“Dirty Bombs”). Atlanta, GA, Centers for Disease Control and Prevention 8. Radiological Dispersal Devices (“Dirty Bombs”). Nuclear Regulatory Commission, 10-US Patent #5635204, United States Patent and Trademark Office, June 3, 1997