 We're talking about Vesicans here this morning and by the way, I'm a dermatologist Vesicans are agents that blister the skin That's just a fancy name for blistering agents This is for a med center in school and to keep everything up and above board You will know for this a these agents at the end most of this No one knows all of this because all the answers aren't in on all of this I'd like to tell you right up front that you know how Involve the treatment of nerve agents aren't everything I want you to relax Because you already know almost everything about rendering the care to a mustard casually because there is no magic bullet for mustard It's all supportive. It's all the good medical practice that you already know. Okay? So all you got to do is listen learn the specific things here, and you already know how to take care of mustard casualties Mustard sulfur mustard is the biggie. I want to spend probably 90 percent of time this morning Talking sulfur mustard and when I get done you'll understand why and also why this old old agent is still one of the top two concerns on the Modern chemical battlefield Nitrogen mustard while very similar has some significant differences and never has been to my knowledge Really weaponized some of its forms are solid some of its forms of explosives some of this forms will eat through the shell So it's never been really used to my knowledge as a chemical warfare agent I would tell you as a dermatologist I have used it in modern days on patients as a topical medicine for a Skiffing lymphoma called mycosis fungoides and still used to this day It was our first chemotherapeutic agent back in the 1930s Nitrogen mustard Lewis site is very similar to mustard with some significant differences, and I'll teach you about those The name Lewis site comes from captain Lewis a US captain Lewis who invented this stuff back in the world We're one time frame. It's my greatest aspiration to have a chemical warfare agent named after me just kidding Foz gene oxyne is Made from foz gene and we don't have another one with foz gene in the name just to confuse you I figured they did that when I took this course, but it's made from foz gene Hence the name foz gene oxyne, and I'll spend just a little bit of time at the end telling you about that because it is important For one or two very specific reasons sulfur mustard first synthesized back in 1822 and then they kind of forgot about it And then it was rediscovered in the mid 1800s way back in the 1800s its first battlefield use was in your pre-Belgium 1917 July Right the last year of the war, okay This is a breakdown of the casualties of World War one there were roughly a million chemical casualties in World War one 30% of all casualties in World War one were chemical casualties But I show you this slide for a very specific reason You've already been told that in World War one less than five percent of the casualties were fatal Okay, and this is the breakdown now if you look at the top three they were under five percent You look at the US and we were at two percent you look at Russia. They were almost 12 percent We came into the war late. We had the benefit of lessons learned We also had the benefit of some of our allies equipment our first mask were not up to snuff So we borrowed French mask initially who had more experience because they'd been in it since 1914 So we were better prepared and better equipped because of lesson learned and because of better preparation and better equipment Our fatality rate was half of the rest of them Russia by comparison you remember those masks that Dr. Seidel showed they look like something that Your your grade school would go in and cut out with cardboard. You remember those really funny look They're all funny looking but the really goofy ones that the That was their mask early on the Russians had little or no protection at times. Their equipment was inferior Their training was inferior and had a 12 percent mortality rate I recently added this one in because I'm trying to make a point about Education and training what a difference it makes and preparation. These are the Kurds Saddam Hussein gassed about five thousand innocent People that were totally unprotected and it wasn't a hundred percent mortality rate, but it was close to it So what a difference protection education and training make Dr. Seidel deliberately preempted me with this slide yesterday But a reminder that even though mustard came into the war the last year of the entire war It accounted for 70% of all the chemical casualties and it's already been made appointment made that the lethality is low It's less than five percent, but it causes long convalescence. It really screws up the medical scenario As a dermatologist, we very often look, but we don't see how many will be say you've looked right at something It was right there playing as a nose on your face, and you didn't see it In times past I have been guilty of going around the house looking for my glasses, and I had them on I Remember my grandfather blessed his soul on occasion would go around the house looking for his pipe, and you know where his pipe was So how many people have done dumb things like that? I hope most of you. I hope I'm not unique Okay, and you know that most of these I'll tell you and show you the percentages of the eye injuries But you know most of these had were in the 75% category had a mild injury that self-healed in two weeks But they were still taken out of action. They were a problem to the fighting effort Okay, we heard that even though there was no actual battlefield usage of chemical agents in World War two there was the Berry Harbor accident, and I Don't think I heard dr. Seidel actually mentioned there were 600 us casualties and a little over 80 Fatalities in that accident. We have no idea how many civilian casualties and fatalities After World War one, you know there have been chemical battlefield uses We know the Italians use mustard against the Ethiopians We think we're almost certain the Japanese use lewiside against the Chinese leading up the World War two We certainly know the Rockies used against the Iranians and the Kurds and it's alleged that Egypt used it in Yemen Now mustard has lots of names and symbols. Most of them have H in it. Okay, so anytime in this course you see H it stands for mustard not Hearst, okay? I don't want anybody going around saying Hearstite or site or whatever here Here's one called HL and it's a mustard lewisite mixture. There's a very specific reason for that I'm gonna tell you about that a little later These by the way were called lead leavens tubes They were like a poor man's mortar and it was one way they shut chemicals out of them in the World War one You saw gas tanks yesterday You see this structure. This is mustard most of these chemical agents have very simple Structure some of them are as simple as water like foiging, you know It's very small molecule and the only ones are complicated more so or the nerve agent ones This substance down here is thiodioglycol and you see the only difference is Between thiodioglycol and mustard or the chlorines on the end Well, thiodioglycol is one of the major urinary metabolites when it's gone through a person or an animal it also is The number one precursor to making mustard in the most simple process of manufacturing and I know if you have Thiodioglycol which by the way is a commercial product using making printers ink and any number of things All you got to do is take thiodioglycol Throw HCL into it hydrochloric acid and walla it makes sulfur mustard a one-step process If you have thiodioglycol and hydrochloric acid you could make it in your bathtub if you were stupid enough Well, there are people they're stupid enough take my word for it not me not me Guess who was buying up all the thiodioglycol he could lay his hands on Saddam Guess where he was buying it from one of the places Germany guess where else he was buying it from US Now guess what the closest city was one of the closest cities he was buying it from Baltimore guess who where there's some got people from there are serving time now Okay They were using intermediate areas. They weren't buying it directly. I don't think but they still were breaking along Mustard is an oily thick substance and at times I have seen it in ball containers It looks just like dirty motor oil. It looks like my motor oil whenever I change it Grungy dirty motor oil heavier than air heavier and water Because it's oily it has low volatility and it's quite persistent now Here's a ringer look at the temperature depending on the manufacturing process Mustard freezes around 57 58 degrees Fahrenheit When I was in the Gulf War and the ground war kicked off the temperatures were below that even in the daytime So Saddam Hussein had thrown pure mustard at us. They've been little ice cubes lying on the ground We could have laughed at so this is a significant factor, but there are ways around that There's more than one way around it, but I'm going to tell you the biggest way around it shortly The M8 Test paper okay turns three colors. You can't read the writing, but the G agents turn kind of orangeish yellow H turns red and V agents turn a dark color black dark green brown You need to know that the M9 tape is all or nothing it turns red if it's exposed to nerve agents or vescans The M256 kit, which by the way is quite good. It just it's an it detects vapors for these detect liquids It's quite good, but it takes about 20 minutes to go through it It detects the vescans it detects cyanide and it detects the nerve agents the vapors You need to know that the cam down here is nerve agents and vescans mustard It also will pick up lewisite, but it'll read it out as mustard. Okay Repeat that I couldn't repeat that twice if I had you know what I'm gonna review you again, and I'll repeat it It's in your little handbook. You really want me to go through that again Well I asked for questions then The end this is representative of the M9 paper and it turns three different colors Okay, and you need to go back and look in the little book. You should try and commit this to memory on the fly The M8. Yeah, it'll turn orangeish yellow or something for the G agents It'll turn red for the Vescans and it turns a very dark color for the V agents The M9 tape, you know, which is what people have on their arms and their legs so you can only cow It's turning colors. I better do something. It's all-or-nothing phenomenon. It turns red if you've been exposed to liquid These are for liquids The M256 kit is for vapors and it's a little kit You got to fold this out and strike this and that it takes and you'll get it do this in the FTX It takes about 20 minutes, but it detects Vescans, cyanide and nerve agents. Okay, vapors The cam you'll see you'll get a handle this and look at it. You won't be made proficient with it in this course But it detects nerve agents and Vescans and remember on the modern battlefield the biggies You're gonna hear hear about in the whole ball of wax in this course But the biggies we're concerned about on the modern battlefield are nerve agents and Vescans and primarily sulfur mustard Okay Mustard when it gets on epithelial surfaces like the skin It takes about two minutes for it start doing its damage So if you can de-con it if you know you got it on you and you de-con it within two minutes or less You're gonna get off scot-free. Okay The problem with mustard is it doesn't hurt you or anything It could feel just like you got a little water on you or something So it's a sneaky peat. It has a latent effect that I'm gonna tell you about 80% of the liquid that gets on the skin evaporates it goes into the air doesn't even damage It's only the remaining 20% that does its harm now They argue about how much does the local damage, but sometimes as little as 10% of that remaining 80% Does the damage on the skin the rest of it gets absorbed and goes systemic You don't have to wrote. This is what you need to know You got two minutes to get it off of you before it starts harming you the molecule I showed you of mustard is not The active moderate molecule when mustard comes into contact with water It cyclizes into a closed little intermediary That's the one that does the real damage and it acts like grease lightning once it it goes into that circular ion Mustard and I haven't said it yet is an alkylating agent just like nitrogen mustard just like cytok and some of the other things What alkylating agents do is they take carbon carbon bonds and rearrange them So you can imagine that if the carbon carbon bonds in your DNA have been rearranged It's not too healthy Likewise it can affect the bonding and the carbon carbon bonds in your your cell proteins your membranes mustard Attacks just about everything it comes in contact with but we know from studies that your cell proteins and especially the DNA and actively dividing cells are the most sensitive targets for mustard and that tells us a lot about the mechanism of action of mustard Thus when your DNA in your cells has been rearranged on your epithelial surfaces It can lead to cell death or mutation in the cells Vapor by and large a mustard or liquid is an epithelial phenomenon The number one sense of area is the surface of the eye the cornea Followed by the airways the tracheal the bronchial epithelium and the skin But if you look at the starting points, they're not that far apart Okay, but your eye is the most sensitive followed by the airways and then the skin Down here is what it takes To kill you you learned about LD 50s and CT 50s yesterday, right? Everybody got that concept straight? Let me give you a hypothetical situation I think you also learned yesterday that mustard is actually twice as toxic twice as poisonous per weight as Sinide, which is a very dramatic agent because it acts so rapidly if you took a meter cubed Or if you took this room and you had a big enough puddle of mustard in here liquid and Allowed it to equilibrate so that the room had vapor saturation vapor saturation depending on what studies you read is around 600 milligrams So you stick your head in a meter cubed closed area with enough liquid to come the equilibration saturate And it only takes how long if that vapor has 600 milligrams in it for you to get breathing in LD 50 unprotected by a mask takes less than three minutes for you to breathe in a Poisonous lethal amount of mustard in a totally saturated atmosphere if you have no protection The skin by comparison if you were wearing a mask and you were totally naked and the vapor was hitting the skin It takes 10,000 milligrams for mustard vapor to kill you through the skin These are all things so you know you have comparisons to trying and grasp somewhat intangible concepts liquid by comparison You've seen some pictures of mustard already. I'm going to show you more But to raise just an insignificant little blister like a poison ivy blister that you know similar It only takes 10 micrograms of liquid mustard Let me remind you that a microgram is a thousand of a milligram milligrams are pretty small to me already But only 10,000 of a milligram of liquid mustard can at least raise a poison ivy type blister on the skin an LD 50 of liquid mustard on the skin is around 7 grams in your classic Svelte 70 kilogram male, you know something like me Well, he knows I'm lying I Want these cameras when you edit this I want you to take 20 pounds off of me you got that So Anyway, seven grams of mustard is a liquid LD 50 now a teaspoon is like five ccs You know a gram is equal roughly to a cc So a teaspoon to a teaspoon and a half of mustard is an LD 50. Okay As a dermatologist I would tell you that if you had suntan lotion or oil and you took a teaspoon a teaspoon and a half You could cover one whole arm and your shoulder front and back and that's about 20% of your body surface area so if a patient comes in with 50% liquid Burns by mustard 50% how many LD 50s have they gotten? You're right. You guys are sharp some classes you asked me Scratch your head and anything it's it's 20 in the 50 I just told you 20% they've gotten two and a half LD 50s How do you triage a person with 50% liquid mustard body burns? You got it If somebody comes in with 90% of their body burns and I'm gonna show you a picture of it I hold your breath when I do later on if somebody comes in with a darn near 90% body burns How many LD 50s have he almost gotten? They've gotten four and a half close to five LD 50s. They're gonna be triage expectant likewise Now I've told you that mustard's primary targets are epithelial cells and that's because those are rapidly dividing cells They they have the most sensitive DNA as eyes airways and skin But it does go systemic sometimes if you get enough of it well It goes systemic all the time, but it depends on how much have you got whether you have a systemic effect But where do you have? Rapidly dividing cells internally the bone marrow the GI tract CNS is not rapidly dividing but we'll talk about CNS later on and of course in lymphoid tissue But your systemic effects that you're gonna see most readily are gonna be bone marrow and GI if you get them Hand blisters. This is a moderate to severe Conjunctivitis with mustard. I'll show you larger pictures of this later on. These are bronchi. This is supposed to be smooth and round You look in here. It's gunked up. You see the pseudo membranes. This is lung tissue. That's messed up This is a larynx tongue. I think you might have seen I don't know if you've seen this one yet or not But this is a crispy critter larynx. This is what I what a non-survivable dose Mustard in the pulmonary tract will do to you. It's just fried. Okay You this probably doesn't show quite as well with the lighting But this is a trachea and these are the bronchi and you see the ratty chunks here You see it should be smooth contour like a nice Pipers a big chunk here how ratty it is. This is looking down on a bronchoscope This is down the trachea and these are the two bronchi. Well, you can barely see any opening They're plugged up with the pseudo membranes and world one some some soldiers died from the mechanical Obstruction of the sloughing of the epithelium. That's what the pseudo membranes are. It's a physical Mechanical obstruction you could take a bronchoscope in these days and go down and suck that out if you had those Capabilities, this is another you know, you see how it's plugged up. I showed you that smaller before Now this is a slide I showed to make a point Depending on which what you read the eyes the lungs and the skin they all come in close 85 90 75 it's all about the same to me. They all got affected in the burn when you got burned And so we expect eyes we expect lungs and the skin also comes in 75 80 percent, but Look what the top area was it got burned and The men are already complaining up here Just goes to show men are dumber than what I mean Look down here the hands and feet You'd almost expect it to be reversed wouldn't you okay? Why do you think this is? Were they all sitting around in puddles of mustard in their shorts or what? What kind of mop suits did they have in World War one? None they had uniforms they had masks, but mostly I was just wearing uniforms in World War one now as a dermatologist I would tell you that Delicate sense of skin is most susceptible to medicines drugs or toxic agents Warm warm moist skin is most susceptible more susceptible and also Occluded skin okay, so where do you have delicate skin? That's occluded warm and moist and then with vapor mustard going right through the uniforms and then kind of being held there It was a real setup for getting the growing burns, okay? I've told you you got that it interacts in one to two minutes you decon it in two minutes or less You're gonna get off scot-free. They used to do this down at in Alabama, Aniston at the Kim School the non-medicals course In the old days when I would have been a young fellow They used to put a drop of mustard a dilute drop on each forearm They would allow them to decon one side in two minutes or less and they didn't get a decon the other side Guess which side always got the blister and a teensy little scar and which side never got anything Well the side you decon clean his whistle side. I didn't decon got the blister Mustard's onset of effects, you know, it's a latent period. It's been called radiomimetic It's just like radiation effects. It's like some other chemotherapeutic agents It's like ultraviolet light from the Sun. You don't know you don't feel anything You don't know you're being harmed at first because of its delayed effects So the onset is usually delayed from anywhere from two hours to two days The average is about four to eight hours Now this probably isn't projecting. Well, but his chest is a little red Mustard starts out and the erythema the redness shows up first Then it progresses to small little vesicles, which is a dermatologic term for small blisters vesicles or small blisters and if you got enough of them They will go on to coalesce to form big blisters or bull eye, which is another dermatologic term for big blisters There is the possibility with liquid mustard if you get a large amount on you and it doesn't get decon You can skip all this. You can go straight to a third degree burn with a black s-scar. It has happened, okay? This is the famous person you might have heard about yesterday Who was working at a depot site a little eyelet on the back of his boot let mustard drip in And I think they say that they calculated that was about a 20 milligram dosage of mustard that made this blister I have seen blisters that probably looked about like this that were caused by as little as the 10 microgram dosage But again two minutes to get it off of you Two hours to two days to the onset Obviously if it takes two days for the symptoms to show up You've got a pussycat of an injury versus two hours two hours. You're in trouble. Okay, especially if it's a large area Average four to eight hours Just a blow-up of a blistered hand with mustard that you've seen the smaller picture earlier Little bitty blisters all over a couple big bull I have formed from the coalescence By the way, there is no blister. There is no mustard in these blisters Hospital personnel medics are absolutely not going to be harmed by the blister fluid There is no mustard in these blisters And this is an Iranian casually who has darn near 90 95 percent mustard burns You can see the giant bull I he is red Red red all over and he was a non-survivor The eye injury the mild conjunctivitis There's an intermediate which is more severe takes longer to heal with edema and even roughing of the cornea swelling and a blephar spasm and then there's a severe category that can be so bad There's even perforation of the of the globe and it could even qualify for legal blindness The breakdown on this is 75% of them had the mild conjunctivitis two weeks and they were they could be back to duty and they Required little or no therapy. They just need a lot of TLC The 15% intermediate took sometimes as long as two months four or six weeks more of a problem But they would heal without residual the remaining 10% were severe with residual damage and by today's standards about point one percent of those patients would have met the criteria for legal blindness And this is a blow-up of the picture of a moderately severe mustard conjunctivitis hemorrhage in the conjunctiva this is a blow-up of the The burned-up larynx tongue Symptoms and the upper airway are going to be hemorrhage pain Horseness strider you can imagine. I mean you're not going to be Feeling like singing any songs with a Trachea or larynx that looks like that Down lower you're going to get bronchospasm caused by the inflammation of all the bronchi and then the pseudo membranes will develop and can plug up the airways With a massive massive mustard exposure. You can get hemorrhagic pulmonary edema now pulmonary edema is not Normally a feature of mustard. This is only with a very massive exposure It is a feature of some of the other agents, but not mustard only with a massive massive exposure there are Three when you die with all these agents by and large you die a pulmonary death I mean all of them not just the Veskins not just the pulmonary agents nerve agents all of me It's essentially a pulmonary death with mustard. There are three types of pulmonary deaths Okay, the first one which is very is very much in the minority Okay, and was it with a massive exposure in the lungs I like it into it as if you had sucked on a blowtorch or somebody poured lye or acid Straight down in your lungs the injury is so massive that you're just torn up down there You couldn't possibly be a survivor and you'll die in one to two days. That is very rare But it's one way you can die a pulmonary death with mustard the most common way and what happened to about 50% Of the soldiers in World War one with a pulmonary injury. They got the lung injury. They got the inflamed bronchi trachea You know pseudo membranes and then along about three to seven days Remember this long about three to seven days the secondary bacterial invaders came along and they got a secondary bacterial bronchonemonia and Guess what they you know what they didn't have in World War one. They didn't have antibiotics That's what took out about half of the soldiers with mustard in World War one. It was a secondary bacterial bronchonemonia that usually shows up three to seven days after the insult The last way you die a pulmonary death with mustard is that at 7 to 14 days and the slide coming up I'll show you this at 7 to 14 days if you've gotten a major systemic hit the bottom falls out of your white count and You get septic because you can't fight infection and you get sepsis and a secondary septic type Pneumonia and that's another way you can die a pulmonary death with mustard And that's what I just said 7 to 14 days the white count drops if it drops below 200 from experience in the Iran or rock war They're very likely you're not going to be a survivor and then you get the secondary sepsis in the GI tract mustard has a Coalinergic effect and it is very poorly Understood or not understood at all and this is nothing like the Coalinergic Effect in nerve agent, but there are Coalinergic symptoms mild ones Early on within 24 hours with a significant mustard exposure that can give you bowel Cramping diarrhea nausea vomiting, but that's transient and it's not the same mechanism as nerve agent later on If the bottom falls out of your white count and it you know you get marrow suppression But also if enough went into circulation and got to the GI tract it can take out the GI mucoso the epithelial surfaces, so you can start Caught vomiting up evacuating Pieces of your GI tract the epithelial surfaces get a hemorrhagic diarrhea, and that's the effect systemic effect on a GI tract Now I don't want you to get the impression that this is like with nerve agent that this is just a Progression, you know like a massive nerve agent exposure But there is a mustard effect in the CNS And it can be apathy and lethargy on the individual or they actually can be giddy and euphoric Why is not understood, but it does happen sometimes with a massive major mustard exposure They can go straight to convulsions and die Okay, but this is not the progression like in nerve agents, and this is with a very large exposure Okay, and it's the minority a very but it has been seen I've told you that mustard has been called Radiomimetic because it has a primary effect at the DNA the DNA of your rapidly dividing Epithelial cells your bone marrow your GI tract Okay, when the symptoms come on within four hours you got a severe injury Okay It's really severe if it's covering it involves your lungs or a large surface area on the body If the airways the symptoms are coming on within six hours, it's often fatal Okay Now in your differential of these blistering agents there's a couple of cases come in and they're not in any real distress You still can think of insignificant things like poison ivy and poison oak We had a case like this in the Gulf War But it was a young trooper who was exploring the old Iran-Iraq bunker where mustard had been stored but had been taken out and he brushed up against the sides and He started with some burning and stinging about 12 hours out and within about 24 hours So he had some little insignificant blisters about like what 10 micrograms would Cause and that was probably a muster. We couldn't prove it. We tried But little isolated cases no no attack known or anything. Yeah, I think just the garden variety stuff You start getting a number of cases in if there's a latent effect It's mustard if it's immediate effect. It's lewis site or phosgene oxy The lab all your findings are non-specific. You already know all this You get you get in the pneumonia. You get fever spikes. You're getting spikes your WBC is a convene infection Chest X-ray if you got infill infill trace starting to show up it probably means pneumonia You do as you would with a normal pneumonia you look for a change in the sputum you look for pure land sputum And you do graham stains if you get positive graham stains or cultures Then you initiate appropriate antibiotics prophylactic antibiotics only will separate Select out a bad bug that will cause you more troubles You've got to wait till the actor shows up and use the appropriate specific antibiotic We did not have urinary thylendike glycol capabilities in country during the Gulf War Anything we try to do had to be shipped back here You now will have that capability in any future actions as there is a lab called a tamel theater area medical lab which will deploy To a situation like that. So you will have sophisticated laboratory capabilities available to you in theater and the next time this happens as Inside I would tell you That before Saddam Signed his last agreement. This laboratory was getting ready to deploy Anybody want to argue with me that an ounce of prevention is worth a pound of cure. I Convinced it Okay With any of these agents with all liquids all liquids Your decontamination can get you off scot-free and that can be just your little 291 kit and get the spot off of you Physical removal is everything in all this. I don't care whether you've got our 291 kit You've got the Germans diet the maceous for for earth. You've got the The Brits Milton solution The Canadians cream. I don't care what you've got Physical removal is what really counts here because no matter what the active ingredient is in these things They don't kill the agent as fast as I want it killed The the very best thing to decon with and be to jump in a shower and just shower yourself clean Matter of fact if I had that option I'd get in it and they'd have to pull me out of it So remember it's physical removal. Don't get hung up on what you're using get it off of you by whatever means you got That's sad and we so we say this late decon protects the medical personnel in the facility That doesn't mean that a casualty couldn't have gotten agent off the mop suit that was lying here and needs some immediate decon Or it doesn't mean that they didn't have such a large amount that some could still be lying there Even though they got to you half an hour later So when possible with these liquid agents you always decontaminate at the earliest possible time This is all common sense for all medical folk. Okay, it's just supportive now down here a Raw denuded area always gets some kind of secondary mild superficial infection going on That's why with these mustard things that are raw and denuded you would use whatever topical antibiotics you have you know the surgeon the sulfa myelin the Bassetrace and Neospor whatever you got it's appropriate right off the bat systemic antibiotics IV antibiotics are held in reserve you can get a secondary Cellulitis you know with the redness and the infection the staff you can get that and you have to watch for in culture And if you do get it then you use appropriate IV antibiotics systemic analgesics Anybody want to argue that that one case Probably needed a little morphine once in a while You use whatever analgesics are appropriate that could be as little as an aspirin or anihistamine all the way up to morphine It is said and I believe it from the literature I read that a goodly portion of soldiers in World War one died just from lack of Modern-day IV fluids and electrolyte and replacements mustard burns are said not to have The severe fluid requirements that a thermal burn does those of you who know have treated He said know that thermal burns take massive amount of fluids Well mustard burns require a lot of fluids But they're not supposed to require the massive amounts of a thermal burn But they do require good IV fluids and electrolyte replacement I Again, it's supportive. There's two things. I want to point out here With a mustard eye injury you want to grease the rims of the eyelid, you know with ophthalmologic ointment antibiotic I ointment Vaseline if that's all you got but you want to keep the rims lubricate and the reason being is that Conjunctivitis is going to produce pus polys. It'll probably be sterile pus But if the eyelid is stuck together from the edema the swelling and held together and that pus doesn't drain out a Sterile abscess just destroys tissue, you know polys produce peroxide so you want that lid To be open and draining, you know so they can it doesn't get trapped behind here This other point here topical steroids in the eye, you know This is a chemical type burn and I've talked to lots of ophthalmologists and every one of them have always told me They would use topical steroids in this injury. We do not have the laboratory data to prove whether this is beneficial or not, but I Would let it be the call the ophthalmologist There are instances obviously if there's secondary infection you don't want to be using a topical steroid alone Also, if the injury is too severe if the the integrity of the globe is breached Putting steroids in the eye and they go straight in can cause, you know, glaucoma problems And so I would buy in large right now Leave it up to the ophthalmologist, but it could be a very important part of their treatment Sunglasses causes photophobia. It was the first use for photophobia or sunglasses a mustard World War one You can you can use topical anesthetics in a couple of situations. I Could envision and I sometimes address this as it passed it by I can envision a casually coming in being Semi hysterical and a lot of pain and you would need topical anesthetics just to get them under control so you could examine them That's one appropriate use Another one would be as I said, so you or the ophthalmologist could examine them topical anesthetics How many have ever had a coronal coronial abrasion? It hurts doesn't it I had one and my friend Ophthalmologist says here. Let me give you some codeine or percocet or whatever it was in those days and me being a macho man I am I declined I just took my patch and went on vacation and I suffered the next two days like you wouldn't leave because it was so painful But I did have topical anesthetics with me like a wise doctor, you know who should ever treat himself you put the drops in for five minutes Goes numb you feel wonderful. You probably could do yourself more damage while you don't feel anything and guess what in five minutes It's right back it doesn't you know you this doesn't work long enough to do squat Okay All everything we know bronchodilators the steroids here are for bronchospasm. They're not for anti-inflammatory There's no indication that we have that it will knock out the inflammation. It's for bronchospasm Atropine this is not like a nerve agent. This is like a preoperative dosage like for Cramping and diarrhea like point three milligrams That's what this would be for for nausea vomiting Diarrhea if you have a co-energic or GI effects of Bustard and we've talked the fluid and electrolyte replacement You know we're talking a lot of World War one data in Iran a rock war because we had we personally Haven't had mustard thrown at us on a modern-day battlefield, and I'm very grateful So we're talking about historical data animal data, etc. I Will bet you dollars to doughnuts that in a modern battlefield if we weren't overwhelmed It wasn't a true mass casualty scenario, and you can get people back to a tertiary medical facility These people that would have died I bet we can save a lot of them, and we'd save them with transfusions, okay We get any there's marrow transplants that work nowadays. We may be able to do hormonal stimulation of the bone marrow erythropo eatin anabolic steroids There some of these things may work and even just reverse isolation techniques to help with the Bottom falling out of the bone marrow It's mustard a cards carcinogen you bet You know there's been a lot of talk about Gulf War illness and what does this and that mustard is absolutely a carcinogen anamutagen there is no evidence to date of Reproductive toxicity in humans there is some animal data of reproductive toxicity And I know there was show on television recently about the Kurds, which I didn't see and it suggested They they may be bothered by report 60 minutes But I didn't get to see that But I'm not going to argue the issue one way or another Chronic exposure does it cause cancer in chronic exposure? Absolutely There's good clear data and people who have been factory workers in the manufacture of mustard who got bronchial cancers, okay? Chronic bronchitis and emphysema We don't know and I'll tell you why because they were primed the best work was done by the British in after World War one and They had about 12% or so of soldiers that ended up with chronic bronchitis emphysema But they were smokers the air in England at that time was Very polluted from burning coal with sulfur in it and also these soldiers that also had a chronic lung Bronchial infection that had to heal without antibiotics. So they had very scarred Bronchi, okay, so they did end up with chronic bronchitis and emphysema. So you can't clearly say what caused what but I Won't bet against it Acutely one or two exposures of no evidence that mustard causes cancer chronic eye problems Absolutely, okay, you get eye damage and stuff you get chronic eye problems a Very, you know low percentage Lewis site captain Lewis World War one that was captain from the US by the way He's never been used except possibly by the Japanese against China leading up the World War two No other known use sparse data on it. It is very similar to mustard with some significant differences Mustard freezes 57 58 the Lewis site freezes and zero Guess what happens when you mix mustard and Lewis site together Drops the freezing point down around zero Where were we gonna? Where did we think World War three would be fought? Europe where it would frequently be low be below those temperatures who had has Lots and lots of mustard Lewis site mixtures You got it. This is the former Soviet Union in it and they still got it Heavier in air heavier water. It's oily substance persistent said the smell like Geranium a mustard stinks mustard smells like garlic onions mustard stinks and you can smell it at very low levels if you have a good sense of smell and Lewis site said to smell like geraniums, so it's supposed to smell pleasantly is Lewis site carcinogenic Arsenic is in the molecule Lewis site. We don't know that Lewis site is carcinogenic But we know that arsenic is certainly a carcinogen the exact mechanism of action of Lewis site is unknown, but the primary pulmonary Lesion in Lewis site is like that of mustard. It is necrosis to the bronchial epithelium, okay? But the exact mechanism is unknown eyes Airways skin just like mustard is primary epithelial targets, but look right here. Here's a new one Lewis site damages capillaries. I didn't say anything about capillaries with mustard Lewis site damages capillaries and causes leakage This is said to be a Lewis site blister that you need to remember that is different from mustard. It damages capillaries Causes leakages. Yes, sir a question. How would these be would these be toyed by being packed into munitions get him on the can Would they be um sprayed and just left in the local area? Say your question again I said sir would these be packed what kind of munitions would they be packed into would they be sprayed on or would they be put like an artillery shells Yes, yes This class is starting to pick up you guys are flat you guys are flat. Yes, this is what I like You can deliver this stuff anyway, it can be sprayed most commonly it is blown up Okay, it was either dropped out of airplanes in an explosive thing and you get an aerosol You know the droplets that then can go on the vaporized, okay? That's pretty good. I like that Lewis I cause immediate pain, okay Mustard you got to the late of it immediate pain in five minutes you're getting tissue necrosis big difference, okay big difference blisters Said to cause more necrosis and mustard to the fact is we have very little experience with this because it's never been used on The modern battlefield very similar to mustard, okay? Except it's going to be immediate Same as for mustard Aha Remember I dwelled on the capillaries one mechanism action away. Lewis. I can take you out Is pulmonary edema and death your capillaries? Get damaged You're getting fluids leaking into your alveoli you get serious pulmonary edema Hemoconcentration hypotension and Circulatory collapse and death just a progression you know bottom falls out of your blood pressure You're drowning in your own fluids and it can take you out. Lewis. I can do that in the lung aha There is a specific antidote for Lewis site unlike mustard which is totally supportive in World War one they came up with British Anti-Lewis site bow or dimer cap roll most time you think you know British anti-Lewis site bow BAL specific antidote against Lewis site remember. I told you arsenic is in the molecule Lewis site Bow is a heavy metal metal key later it key lights up Lewis site and it does work It's also used in other heavy metal poisonings, okay? It comes in all three forms topical ophthalmologic and systemic Don't even memorize this if I ever have to use this I'm gonna go to a little handbook and look up the mounts, but this is there are directions for using it You ever heard that the treatments as bad as the cure? Well, there are side effects to bow. They're not show stoppers, but It's kind of stuff if you didn't have to take it you'd rather not Fosgene oxyme I thought when I took this course a hundred years ago It wasn't bad enough. There were so many names and symbols They had to go have one called Fosgene and one called Fosgene oxyme. Well, Fosgene oxyme is made from Fosgene That's why you get the name and a CX not CG It is not a blistering agent It is a very corrosive substance that's said to be an urticant Urticants cause a hive-like lesion before it goes ahead and rots your skin off Very little known about it Here's why we stay concerned about it. They got its stock piled. Okay, the former Soviet Union and they still got it It's a very corrosive substance while Fosgene is only a lung amp agent has no effects on the skin Fosgene oxyme is a a corrosive Epithelial agent, but obviously if you get this in the lungs it also is a pulmonary agent management There's no magic bullet. It's everything, you know just like mustard totally supportive I would tell you though that with any any liquid agents and We're talking about Veskins now today, but with any liquid agents. What's the number one thing you do if you can? Decontamination, okay, don't forget that you'll see it again This is a mini pickup truck from Saudi. Okay, and those are camels. That's those are camels And the question is this is your test question. I promised you How many camels can ride in the mini back of a mini pickup truck? One wrong answer the answer was two You just kept going up. You'd eventually hit it, right? There's three okay three back there one's facing out this way one's facing right at me and no one's facing out that way and I never cease to be amazed and Saudi This is this is not even a long bed mini This is one of the little me and it's three big camels sitting in the back of that truck happy as larks That's right. I don't and you saw I mean you can ask anybody else there If they didn't they saw this too, and I guess this just goes to show that Camels are rather right a mile than walk a mile Questions sir could you mention anything about the topical skin protects skin protectants that are yes We have developed a topical skin protectant here As all kind of side stories I can tell on this But I'm already over and if you gab grab me at the break I can give you a color commentary on these But we have a skin protectant that's in advanced development, and it's made from a commercial oil We had to get the right texture and it's got these particles in it They're actually Teflon particles and you got to get the right mix and it protects You can put it on your skin in closure areas, and it will increase your protection on the bare skin to agents up to like four five six hours and Envision to be put in the closure areas, okay the Institute and Colonel little will talk to this at the end of the course We always bring me because we'd like you to know we don't touch on all the neat things of stuff That's going on here for the future, but there are there's Lots of ideas for better protection down the line We also work on a second generation of what is called a reactive topical skin protectant Where and we're trying a lot of different things, but they took the regular Topical skin protectant that's already in advanced development And one thing we did in World War two they were experimenting with all these topical protectants And I brought some 80 year old scientist up here who is a guy in inventus s3 30 in World War two He's still alive PhD sharp as a tank. We took his old Material s3 30 put it in the new topical skin protectant and it doubled the time of the current one and it's reactive destroyed So they're working on you know that may not ever be the The second generation, but we got lots of good leads, okay? Yes, do any of the agents of the other agents to stay in the vesicles No, not to my knowledge now reason I made a point of Bringing that out is There are crackpots around the world that publish all kind of things and every few years Somebody will come up with my record and say aha We found live mustard and a blister fluid that has been tested over and over again That's not true. Okay, and I don't want and I'm not aware that any of the other ones would stick around They react too fast. They're gonna damage tissue. I mean It doesn't even make sense that they would still be there. Okay