Main Points

• Emergency physicians are essential to ensuring that hospitals and communities are prepared for disasters and the nation is prepared to respond to terrorism.
• Emergency physicians serve with EMS providers, firefighters and police as first responders to disasters and acts of terrorism.
• Only a tiny fraction (4 percent of $3.38 billion) of federal funding for emergency preparedness has been spent on medical preparedness, according to Institute of Medicine reports released in 2006.
• ACEP is advocating for Congress to provide funding to establish a real-time disease surveillance system. Dr. Brian Keaton is representing emergency medicine on a federal government task force investigating, among other health IT issues, the protection of patient records in the event of a terrorist attack.

For a complete list of items to keep in a disaster supply kit, see ACEP's Family Disaster Preparedness Fact Sheet.

Additional Background on NBC Effects:

Nuclear/Radiation

Nuclear weapons are either explosive (from release of atomic energy through fission or fusion) or radiological. Once used, they can continue to inflict health problems for years.  A "dirty bomb" is a conventional explosive salted with radioactive isotopes to contaminate a wide area. Its destructive power would depend on the size of the conventional bomb and the volume and nature of the nuclear material.  In a nuclear explosion, bomb materials expand rapidly, producing a high-pressure pulse, or shock wave. The shock wave moves rapidly out from the exploding bomb, accompanied by winds greater than hurricane force. The high temperatures of the explosion form a fireball ¾ an extremely hot incandescent mass of gas.  That fireball emits a flash of heat radiation that spreads over large areas, with steadily increasing intensity.

Radiation, when absorbed by the body, can cause serious injury. (See www.va.gov/emshg "Medical Treatment of Radiologic Injuries" for additional RDD information.) The major effects of a "dirty bomb" are likely to be injury from the explosion itself and the psychological effects rather than direct effects from radiation. After a blast, most people will seek emergency care for traumatic injuries, and the management of radiation exposure will be secondary.

Heat radiation from a nuclear explosion can cause flash burns on exposed skin and initiate fires as a secondary effect of the blast wave. Radiation exposure also may occur without a nuclear blast.

Biologic Agents

Biological weapons can either be pathogens (disease-causing organisms, such as viruses or bacteria) or toxins (poisons of biological origin). These extremely lethal substances can be disseminated by various means, including aerial bombs, aerosol sprays, explosives, and food or water contamination. Depending on atmospheric conditions and the agent itself, clouds of infectious material could travel several hundred kilometers in a particle size that, when inhaled, is delivered to the airways. However, multiple factors, including particle size, stability of the agent, wind speed, wind direction, and atmospheric conditions can alter its potency.

Both pathogens and toxins are slow acting, when compared with most chemical weapons. They are invisible, odorless, and tasteless when dispersed as a small-particle aerosol. The lag time between infection and appearance of symptoms may make it difficult to determine the exact time or place of a bioterrorist attack.  Mass casualties may occur with aerosolized dispersal. Some biologic agents are transmissible from person to person and can spread rapidly in an urban environment or through mass transportation. Biological agents do not result in obvious external characteristics that distinguish them from everyday illnesses such as flu (influenza), pneumonia, or chicken pox. Therefore, detecting them, even when symptoms occur, may be difficult. Treatment must be initiated as quickly as possible. Biological agents can be classified into major groups:

• Bacteria: Examples include anthrax (Bacillus anthrax), pneumonic plague, and tularemia (Francisella tularensis). Symptoms may not occur for 1 to 5 days and are usually fatal without swift treatment.
• Rickettsiae: An infectious agent, such as Coxiella burnetii, which causes Q fever.
• Viruses: Examples include smallpox, equine encephalitis, and viral hemorrhagic fever. They can be genetically modified to increase their deadliness.
• Yeasts and fungi, which can be used to produce biological weapons.
• Toxins (poisonous chemicals, often proteins, produced by microbes, plants, or animals) include:
  • Botulism (Clostridium botulinum), which causes acute food poisoning that produces muscular paralysis resulting in death;
  • Ricin, derived from castor bean plants; and
  • Mycotoxins produce nausea, vomiting, diarrhea, skin irritation and potential fatalities.

Chemical Agents

Like nuclear weapons, chemicals may be considered weapons of mass destruction. Technological advances, easy access to raw materials, and availability of technical information (e.g., from the Internet) may contribute to the proliferation of chemical warfare agents.  Preparing for chemical incidents must involve education and training of emergency personnel, disaster planning, public education, deployment of specialized teams, and stockpiling of appropriate antidotes. As with any disaster, the initial response will be local and it will be some period of time before state and federal assistance arrives. Emergency physicians are a critical link to the community for local preparedness.

Chemical agents can be potentially catastrophic, impacting hundreds to thousands of people. Typically, they fall into several categories.

• Nerve agents (e.g., tabun, sarin, VX, soman) affect the transmission of nerve impulses. They are extremely toxic and have a rapid effect, and may cause death within 15 minutes of exposure to high concentrations when absorbed through the skin or respiratory tract. Effects can also be delayed. As gas, aerosol or liquid, a nerve agent enters the body through inhalation or through the skin. Poisoning also can occur through consuming contaminated liquids or foods.  Symptoms of nerve agent exposure include increased production of saliva, runny nose, feelings of pressure on the chest, constriction of eye pupils, accompanied by headache. Other symptoms can be tiredness, slurred speech, hallucinations and nausea.
• Blister Agents (e.g., mustard gas, lewisite) cause wounds on the skin resembling burns and blisters and are highly irritating to the eyes. Considered primarily incapacitating agents, they produce severe injuries.  Mustard gas has an odor of rotten mustard and attacks the respiratory system when inhaled, as well as causes internal and external bleeding. Unlike other chemical agents, symptoms are delayed, beginning 4 to 12 hours after exposure. With extreme exposure, mustard gas is fatal, with the most common cause of death being complications of lung injury.
• Choking agents (e.g., chlorine gas, phosgene gas) affect the respiratory system. Chlorine gas has a choking smell, and inhalation can cause suffocation, constriction of the chest, and tightness in the throat.  After severe exposure, the lungs can fill with fluid, resulting in potentially fatal injuries. Phosgene is a colorless, poisonous gas that smells like musty hay.  When inhaled, it reacts with water in the lungs to form hydrochloric acid and carbon monoxide.  Inhalation causes severe lung injury, the full effects appearing several hours after exposure. Chronic lung damage is a potential long-term health consequence of exposure.

Poison control centers will be an important resource to provide valuable information about the characteristics of agents, agent toxicology, clinical effects, and medical management. In addition, the use of public warning systems will be critical to inform the community about the nature of the incident and appropriate measures to protect themselves.