A new breed of medical horror

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A new breed of medical horror

Hospitals may not be ready for nerve gas, smallpox, or a radioactive bomb


'I just wish we had more patients," said Mark Smith, emergency chief at Washington Hospital Center, two days after the terrorist attacks. Smith didn't want more carnage; he did want to save more lives. But though his hospital was expecting a massive wave of injuries from the nearby Pentagon, the region's primary trauma center took in just 10 victims. Only as the day wore on did he begin to realize that the scarcity of injured meant most victims had perished at the scene.

Smith may yet see an attack, however, that creates dozens, hundreds, or even thousands of casualties. Intelligence experts believe that Osama bin Laden has been trying for years to obtain enriched uranium usable in a "dirty bomb" that could spread radioactivity over a city. He may have pursued bioterrorism agents like anthrax, smallpox, and the bubonic plague. And the components for nerve gas may be frighteningly easy for terrorists to obtain–though, like bioagents, very difficult to make into a weapon. "If I have indeed acquired these weapons," bin Laden has said, "then I thank God for enabling me to do so."

Are Americans at risk? The federal government thinks so. It has spent billions of dollars on antiterrorism measures since the 1995 sarin nerve-agent attack in Japan's subway by the Aum Shinrikyo cult. One hundred twenty cities around the country have received federal funds to develop emergency plans and conduct simulations of chemical and biological attacks. Some cities say they now feel fairly well prepared for a chemical disaster. But others aren't, and hospitals all over the country say they're not truly ready for biological attack, to say nothing of nuclear radiation. "We can deal easily with 10 severely injured people," says Anthony MacIntyre, an emergency physician at George Washington University Medical Center who was part of the Pentagon rescue effort. "We can't deal with thousands. No one is prepared for Armageddon."

Safety first. Released in a shopping mall, subway, or at a place like Disneyland, nerve agents like sarin, soman, or VX would hit people quickly and dramatically. Tests have shown that firefighters can protect themselves, if they use duct tape to seal their uniforms and wear their regular breathing apparatus. But police officers and emergency workers would have much less protection. And while some counties' fire engines have started carrying antidotes for nerve agents, most do not. So rescue forces are purchasing their own masks. "I'm not interested in sending my people out to become what we call 'blue canaries,' " says Patrick Sullivan, sheriff of Arapahoe County, just outside Denver.

Ordinary people, not rescue workers, of course, would need the most help, and many–still contaminated–would find their way directly to the hospital. So hospital workers would have to diagnose and decontaminate. In chemical assaults with skin-burning agents, about 80 percent of the substances can be removed by shucking clothes. The rest can be taken off by a warm shower, and many hospitals have plans to turn their parking lots into emergency decontamination posts. Nerve gases and radiation poisoning are harder to identify, and if terrorists unleashed a clandestine biological attack, it could take weeks before health officials even realize there is a problem. Agents like anthrax and smallpox produce early flulike symptoms. A smallpox simulation called Dark Winter, played out at Andrews Air Force Base in Maryland in June, showed that a well-coordinated attack with smallpox or plague could kill hundreds of thousands of people.

Most terrorism experts agree that surveillance needs to be stepped up: Specifically, cities and states should gather data to look for odd patterns, such as an unusual number of school absences in one neighborhood–especially outside flu season. New York already has one such system. And just last week, officials in Baltimore were scrambling to get a Web-based operation going to allow area hospitals to report numbers of flulike symptoms as they turn up.

Overwhelmed? Hospitals do have some of the technology and medicine to treat many attack injuries. Nerve gas victims get atropine, a drug often used to treat heart attacks. Chemical-burn victims are treated like other burn victims, with pain medication and measures to prevent infection. Radiation victims are at risk for organ failure but can be treated with cancer drugs like interleukins. And those infected with dangerous bacteria get heavy-duty antibiotics.

A big part of effective medical response is guaranteeing availability of supplies. If, for example, all the hospitals in one city order anti-infection masks or drugs from the same vendor, and if they run low at the same time, that could cripple the supply line in a crisis. To avoid supply problems, the government has developed a National Pharmaceutical Stockpile with caches of vaccines, drugs, and medical equipment like syringes and face masks stored around the country. It was activated for the first time on September 11.

Blood supplies pose a similar problem. The recent terrorist events showed that nationwide, the American Red Cross's collection locations weren't staffed adequately to screen potential donors and process blood. Donors waited in lines five to six hours long. So the agency is now developing a "Mercy Corps" of trained medical volunteers available after a disaster.

If hospitals are not well prepared, it's partly a matter of simple economics. After a decade of cost-cutting and downsizing, gearing up for a terrorist attack has been the last thing on the minds of hospital chiefs. There's a reluctance to use space and money to build decontamination bays inside hospitals, bays that might rarely be used. "Administrators live in a 'put out today's fire' world, not a 'hope it never happens' world," says Lew Stringer, medical director of state emergency management in North Carolina. "And you can't blame them for that."

It's especially hard to cast blame when some experts say the most alarming scenarios are highly unlikely. Amy Smithson, an expert on chemical and biological weapons at the Washington-based Henry L. Stimson Center, thinks the threat of this kind of attack has been exaggerated. "I'm seeing a lot of people say things on TV that really irk me," says Smithson. "Such as, 'It's easy' or 'It's inevitable.' It's neither." Aum Shinrikyo, for example, had Ph.D. scientists, millions of dollars, and years to work on biological and chemical weapons. All its biological efforts failed, and its sarin attack–at the height of rush hour in the world's busiest subway system–killed 12 people.

Others disagree. Rice University chemist James Tour says he recently purchased through the mail for a couple of hundred dollars enough chemicals to kill 50,000 people. Still others say that the question of whether terrorists can obtain chemicals and make weapons is largely irrelevant. "The thing that actually scares me is sabotage," says Jonathan B. Tucker, a terrorism expert at the Monterey Institute of International Studies in California. A terrorist attack on a chemical or nuclear plant could create a Bhopal- or Chernobyl-like disaster.

So hospitals and others may have to start living in a "hope it never happens" world after all. After September 11, they really don't have a choice.

With Mary Brophy Marcus and Ben Wildavsky


-- Martin Thompson (mthom1927@aol.com), September 23, 2001

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