 Time is creeping up on us, and I'd like to take us back to those fearless medics at the 405th Combat Support Hospital and see just how they're doing. So let's take it to the 405th. Colonel Noel. Colonel Cooper. Colonel Cooper, the PMO. Glad you could come. What have we got here? Well, I'm very worried that we have an infectious process going on. We have a number of patients from the same unit. They all have pneumonia, fever, chills, they all have amoptysis. A number of the patients have hemorrhagic rash. TKI, perpura, and from the history from these patients, it seems it affects a almost entire unit. I'm very very concerned we have a significant outbreak here. Well, we've been getting DNBI surveillance reports from units all over the area here all day long, and there's a lot of things that they seem to have in common. Why don't we take a look at the patients and see if we can flesh out what their symptoms are in common, and in the meantime just continue your appropriate therapies. Okay, here's one of our sickest patients here. He's on intravenous rosephan, IV erythromycin. We've got... Roger that. Yes, sir. We'll be looking for us. Folks, bring it in. What's going on? Well, you definitely have an outbreak here. The patients all have very similar symptoms. They're from the same unit. And we haven't got an exact attack rate yet, but I'm going to assemble my team and start a full outbreak investigation. Sounds really bad. Just talked to the vision surgeon. Told him that we have a significant outbreak here of an infectious process. He told me that there's at least 10 more patients due in from the battalion A station with similar symptoms. So we've got a big problem here. Well, it sounds like somebody's got a right standing order on these patients, so I'll take the responsibility for that. Sir, shouldn't we separate these patients from the trauma case? That's a good idea. Why don't we cohort isolate them separate from those patients and make sure that the staff uses protective masks and universal precautions caring for them? We can use ICW-2. I'll go get the medics to prepare for standing orders. Great. Okay. Dr. Cooper, some of these patients are very seriously ill. We got them on rosephan. We have them on erythromycin. Is there anything else that we can do while we're waiting the cultures or do you have any idea what's going on here? We don't have an agent yet, but there's been some disturbing reports from some of the troops. They said there were shelled a couple of nights ago. The shells didn't explode, but made a hissing sound. What do you think that means? It could mean that this is an intentional event. There's been no reports of civilian illness, no animal die-offs from the ESO. I'll have the check with the MBC officer about BIDS alerts and see if they've been confirmed by the Tamil. Meanwhile, I'll check the culture reports and check on some of these patients. Some of them look pretty ill. And I'm going to get on those standing orders right now. Fellows, two different types of surveillance activities. I'm going to split you into two groups. You two are going to be conducting case surveillance activities within the unit here in the hospital unit. There's the forms that we're going to work off. You guys here, we're going to be going out to the involved unit and conducting a surveillance activity there so we can calculate some attack rates. So two different teams, two different types of data collection. This stuff is real important for what we're going to do. Any questions? Okay, let's split up and do it. We've got our epi-curve plotted here. You can see the number of cases plotted over time with the hour of onset of illness. What does this line here mean? Well, that's the actual number of cases that that occurred around 0730. It looks like it's about 14 of the cases. Okay, so what do you think of our scenario? What's going on now? Any questions? There was no animal die-off. Is there any significance to that? Is there a significance to an animal die-off? In general, if I understand your question, there could be. And I think you heard some examples from Major Court of Peter about plague. And I like to use the example of Venezuelan equine encephalitis. That's a disease that typically affects equines, as the name implies. If you had a horse die-off or equine die-off and then started to see human cases of encephalitis, that would be the way we would predict that would play out naturally. On the other hand, if Venezuelan equine encephalitis were used in a sinister manner, were blown out there in aerosol form intentionally, you would expect to see human cases either before or in conjunction with perhaps the equine cases. So, sometimes knowing whether there's been an animal die-off or not is helpful. I hope that answers your questions. So again, it might be a clue of an unnatural event. Now, we've spent time trying to understand how triage applies to the biological battlefield. We've talked about how the epidemiologists do their job and how to help the epidemiologist do his job or her job. We've talked about how to help the laboratorians do their job. Now, while Lieutenant Colonel Cooper, who was acting as the PMO in our scenario, is investigating his outbreak, let's move on to the nuts and bolts of diagnosis and treatment. We'll get down to helping the patient now that we've helped other people. Well, great. And to help us with our discussion on treatment, we have asked our colleague, Lieutenant Colonel George Christopher, to join us. George has uniquely qualified to speak about this subject. He is an infectious disease doc, and he led the working group to develop the Army's doctrine for treating BW casualties in the field. Welcome, George. Thank you, Mark. Field Manual 8-284, treatment of biological warfare agent casualties is a tri-service field manual with comprehensive guidelines for diagnosis and therapy at all echelons of care. It will be published by the end of December, and will also be available on the Army Surgeon General's website at www.nbc-med.org. George, are we going to get a copy of that with signature? Who are? All right. How about royalties? You making any royalties? Unroyalties. All right. Well, Ted, as you highlighted yesterday, you talked about some of the clinical hallmarks for certain diseases. Can you go over those again briefly to remind the audience? Okay. I think that would be useful. Remember, we would hope that after familiarizing yourself with the classic presentations of anthrax, plague, smallpox, and botulism, you would readily recognize those diseases in their full-blown form. And again, to review, if you saw a patient with a widened medial stynum on the battlefield, there was no history of trauma, there was no bullet hole through the center of the chest, that's probably anthrax. If you saw a bloody sputum in an otherwise healthy young troop, especially if you saw it in multiple otherwise healthy young troops, that ought to make you think plague. A synchronous, postular exanthum ought to make you think smallpox, again, especially if you have multiple patients with that. And again, flaxid paralysis on the battlefield, again, in multiple patients, ought to make you think botulism. Now, that's all easy to talk about here in the studio. But obviously, amid the fog and confusion of war, things aren't always going to be that easy. Patients aren't always going to present in tight clusters. They may not always present in classic form. As you've seen in our video scenario, they certainly may be mixed in with conventional battle casualties, maybe chemical casualties. And unfortunately, diagnosing these diseases probably won't be as easy as I may have led you to believe yesterday. That's right. Most of the potential biological warfare diseases will present simply as undifferentiated febrile illnesses during the early or prodromal phases before they progress to a characteristic clinical syndrome. Some, such as brucellosis or Q fever, will present as fevers without any localizing features even when fully developed. In addition, the differential diagnosis of these febrile illnesses will include the naturally occurring endemic diseases such as malaria or typhoid fever, depending on the geographic location. You know, unfortunately, things I think are made even more complex when you consider that there's really multiple portals of entry for each of these biological warfare agents into the body. And that may influence how the disease presents, of course. So disease presentation can vary depending on the route of entry. And we've touched on that somewhat. But again, let me reiterate. Bubonic versus pneumonic plague. We talked about that. Bubonic plague can occur naturally, but pneumonic plague sometimes also occurs naturally, but ought to make you think that you're dealing with something sinister. And that's the type of plague that you would expect to see if you contracted it by the aerosol route. I also mentioned SCB food poisoning. Already you get gastroenteritis symptoms, vomiting. If you ingest the toxin, you get pneumonia-like symptoms if you inhale the toxin. So the disease manifestations are different depending on how you acquire the agent. Now, with that said, though, some diseases will have the same presentation regardless of the route by which you acquire them. And George, I think you realize very well that foodborne botulism probably would look every bit like inhalational botulism. Most of the viral diseases, of course, are going to follow that same paradigm. Some of them, and I like to use VEE as the example, may play out in a little bit different timeframe. If you inhale VEE, you get it into your olfactory bulbs immediately. It may get to the brain quicker. You may have a shorter prodrome. But again, I think basically the clinical manifestations would be the same. Right. You agree with that? Exactly. Well, Ted, you're a pediatrician and Mark's an internist. As clinicians, we are aware that a careful history and physical will lead us towards the diagnosis 90 percent of the time. Now, we've already discussed all those historical tidbits that might clue us in on the fact that we're dealing with an intentional biological release. Are you aware of a tight cluster of patients with a similar illness? Were only unmasked patients affected? Are you aware of dead animals in the area? What historical bits of information will hone you in to a specific diagnosis? Well, we even talked about this during the question answer or somebody had a question. What about immunization status? I think I'd like to know whether everyone in my units had their anthrax shots or other immunizations which are up to date. Wouldn't that help you in your differential diagnosis? No, I think it would. In fact, I agree entirely. It's not impossible that someone could be fully vaccinated and still contract anthrax if they were very near ground zero. Certainly, I would think that their chances would be dramatically lessened. So, it would be useful to know if they were vaccinated. You know, and Ted, as George alluded to, even those diseases that can have an easily recognized classic form might present initially as nonspecific febrile illnesses. Now, can you tell us a little more about that? Yeah, I think it's useful to understand that full-blown anthrax is easy. It's a no-brainer. If you see a wide media stynum, especially a cluster of those, there's no bullet holes, that's anthrax. Unfortunately, if you make your diagnosis of anthrax in that manner, it's probably too late to save that patient. Private snuffy with the wide media stynum, unfortunately, is the canary. And your job out there is not to save the canary, although of course we're going to try to do that. We want to do that if we can. But your job is really to try to learn rapidly from private snuffy and use his case to make the assumption that if he got affected, a lot of other people may have got affected, and if I can get to them quick enough, maybe I can save them. So the full-blown case may be relatively easy, but I think you understand that anthrax in its prodrable form is likely to be very nonspecific and making the diagnosis there would be virtually impossible without a great deal of clinical suspicion. Right. Smallpox patients can have a nonspecific febrile prodrome for two to four days before the onset of rash. You know, and although pneumonic plague could produce bloody sputum, if we catch a patient early, they may just present as a nonspecific fever. That patient may also produce, fail to produce very much sputum even in the early stages of the disease. Right. Pneumonic plague could take a dare to declare itself as pneumonia. Of course, by then, unfortunately the horse may already be out of the barn. If we wait, you know, over 24 hours to treat someone who's symptomatic with pneumonic plague, you might as well just call the undertaker, because by then, their chances of survival is pretty low. You know, it would be nice if we could simply say, I'm going to assume every case of battlefield pneumonia is plague until proven otherwise. But unfortunately, there's several other biological warfare agents that can cause pneumonia as well. Exactly. Tularemia could present like this. Tularemia can be considered a plague-like illness, although milder. The point is, if you're considering a diagnosis of pneumonic plague, consider tularemia in the differential. And in fact, I want to take this opportunity now to talk briefly about tularemia. Again, we didn't have time to talk about tularemia yesterday, but I want to say a few words about it, because it is on the Centers for Disease Control's threat list. Now, when they devised this threat list, they went about it with the approach that we can't predict necessarily what every terrorist and nutcase out there might conceivably think makes a weapon. So we're not going to try to do that, but rather we're going to look at what, if used, would give us the greatest consequences or yield the greatest consequences. And anthrax, smallpox, botulism, and plague, I think there were no doubt that those agents belonged on the list. But tularemia also is on that list for several reasons. First of all, it's very, very infectious, so it takes only a few organisms to infect you and compare that to anthrax, which requires 8 to 10,000 spores. So again, let me say a little bit about tularemia now. Well, depending on whether you're a lump or a splitter, there are several different forms of tularemia. And we speak of the ulceroglandular form, the glandular form, the pneumonic form, the typhoidal form, et cetera. The ulceroglandular form is the form that occurs most commonly naturally, and it occurs by being, when you are bitten, say by a tick or by a deer fly that has fed on an infected animal, a rabbit, a muskrat, et cetera. And that's the way that we naturally expect to see tularemia. But there is a pneumonic form and a typhoidal form of tularemia, and those are the forms we would expect to see if it were released as an aerosol. And again, they would cause or the tularemia can cause pneumonia, which could be, as George said, confused very easily with plague pneumonia. Q fever and meliodosis could also present as pneumonia. Right. In fact, as I recall, Ted, meliodosis can be confused as plague as well. Well, you know, certainly Tom Butler thinks so. And in that India outbreak that Dave Dennis talked about earlier, they weren't sure whether some of those cases were plague and wondered, in fact, if some of those cases were meliodosis. So, again, you could see the confusion that could be. Right. Both plague and meliodosis are on biological weapons threat lists. Both can cause severe, rapidly progressive pneumonias, and the organisms have similar standing characteristics. Some of the toxins when inhaled can produce pneumonitis due to inflammation and tissue necrosis. For example, stavococcal enterotoxin B and ricin. Right. All right. Well, so we've talked about which of the diseases present as nonspecific febrile illnesses as well as pneumonias. Now, George, in our field scenario, patients with hemorrhagic manifestations are seen. Now, those manifestations we've seen included patechia, perpura and hermoptysis. Now, yesterday we heard that that could occur with plague. Now, what else could be in the clinical picture? The viral hemorrhagic fevers are characterized by bleeding diathesis. The hemorrhagic fever viruses belong to four families of lipid enveloped RNA viruses. They could be biological weapons candidates, since some may replicate well enough in cell culture to permit mass production and weaponization. They are infectious by aerosol and cause severe disease with high mortality. Although most will not survive very long while aerosolized, the addition of stabilizers could enhance their weapons potential. Well, you know, I'm glad you mentioned viral hemorrhagic fevers, George, because that's another agent that we didn't have time to cover yesterday. But again, another one that is on the Centers for Disease Control's threat list. So, I want to say a few words about that as well, just like I did with Tullaremia. Now, you, Sam Redford Dietrich, is famous for its work with Ebola, but in many of our minds, Ebola is really not the best of weapons. And that's because it's not that easy to contract Ebola. Ebola is usually contracted by intimate exposure with blood and body fluids. So, you need to be down in the blood and the guts and the gore to have a very good chance of contracting Ebola. At least we thought so. On the other hand, we are aware, or at least Ken Alabeck alleges, that the Soviets weaponized Marburg, a close cousin of Ebola. So, apparently, there are some people out there who do think that these would be viable weapons. The Almschenrikyo, for example, sent teams to Zaire to try to obtain Ebola. So, they apparently thought these were good weapons as well. So, when the CDC approached this issue again, looking at it not necessarily from the perspective of what would be most likely used, but what if used and if effective would have had the most devastating consequences. I think that's one of the reasons these viral hemorrhagic fevers deserve our attention, Mark. You know, and Ted, those diseases are pretty bad diseases. But, you know, if there is any good news about them, some of them are potentially treatable. Why don't you talk about that? Well, that is true. There is a drug, ribovirin. I think ribovirin is familiar to pediatricians, certainly. We used aerosolized ribovirin to treat neonates with respiratory syncytial viral pneumonia. And there is the potential to use ribovirin in treating some of these viral hemorrhagic fever cases. Right. Ribovirin is active against the arenaviruses and some of the bunyviruses and could be available on a compassionate use basis. Unfortunately, it has no activity against the filoviruses, Ebola, and Marburg. Okay. So, George, we've heard about the viral hemorrhagic fevers. And that, you know, they could certainly cause batikiae, purpura, anekimosis, you know, basically characteristic of a coagulopathy. Are there other BW diseases that could present with dermatologic manifestations? Brison intoxication can cause thrombocytopenia and bleeding. Yesterday, we saw dramatic examples of the postular axanthum of smallpox. Cepsis, due to meloidosis, can also cause a diffuse postular rash. The mycotoxins can cause cutaneous injury due to local effects. It's important to note that anthraxantularemia, when delivered as aerosolized biological warfare agents, will not produce the characteristic skin lesions seen in naturally occurring cases, as Ted alluded to. This is because of the respiratory portal of entry. A review of the cutaneous manifestations of BW agents is in the March issue of the Archives of Dermatology. Of course, George is being a little modest here, but he was actually one of the co-authors on that paper. But I think it's also worth noting that some of the BW diseases are chiefly characterized by their neurologic manifestations. Now obviously, flaxid paralysis should make us think about botulism, as, you know, we've heard a bit about already, Ted. That's right. Botulism on the battlefield would present as a case of flaxid paralysis and one case of flaxid paralysis might be tough. It might call to mind a fairly broad differential diagnosis, Guillain-Barre syndrome, Myasthenia gravus, Eaton-Lambere syndrome, et cetera. I think though that multiple cases of the same thing of flaxid paralysis really leave little room for doubt. So I don't think that there are too many other neurologic diseases that would be confused with botulism on the battlefield. Superficially, maybe, there's one other agent that causes neurologic symptoms, and that of course is the chemical agent to class the nerve agent. So the question is, can we differentiate or how can we differentiate nerve agent intoxication from botulism? All right. Well, we're going to have a video about that now because some people do find that's confusing. Before we roll that video, though, I'd like to thank George for being here and we'll be seeing George a little later on camera. Okay, today we're going to discuss the case of specialist Kern. Where are you from, Kern? New Jersey, sir. Great. Before we do the actual patient discussion, though, let me set the stage here. The scenario is this. It's 1998 and we're at war with the Soviet Union. The nations, the former Soviet Union, have decided they really weren't doing very well on their own. They reformed the new and improved Soviet Union, and now they're not messing around. They're not taking any chances. They've launched a free, full-scale assault over the pole, through Canada, and have plunged deep into the heartland of the United States, and right now the front lines of the battle are raging in and around that critical government think tank at Fort Leavenworth, Kansas. You, though, are here with the 28th cash at Sleepy Fort Bragg, a thousand miles from the front. Nothing going on here at all. Very quiet day at the 28th when in Staggers, specialist Kern, and his story goes something like this. Three days ago, he was pulling guard duty. Some kind of alarm went off. He really wasn't sure what this alarm meant, but all his buddies started getting their mop gear. He figured he better get his mop gear too, but he didn't have his mop gear with him. So he runs back to his tent to try to get his mop gear, trips on the way, hurts his leg, ends up taking them 10 minutes to get in his mop gear. But 30 minutes later, the all clear sounds gets out of his mop gear, and other than a sore ankle, he feels fine. For the next two days he goes about his duties, no problem, feels fine. Now in the morning of day three, he staggers into your sleepy aid post here at the 28th cash, and he says, you know, Doc, you gotta help me. Having a hard time. Can't catch my breath. I feel real weak. What do you guys think going on with current here? The flu? Flu, good. Where are you from, Frut? Georgia. Georgia, good. Flu, absolutely. Influenza, very common disease that occurs in wartime just as well as in peacetime, and in a scenario like this, especially a scenario a thousand miles from the front line, it's far more likely you're going to be thinking garden variety types of diseases like the flu. Maybe he's got the flu. Maybe he's got mono. Maybe he's just scared that he's going to be sent to the front. Maybe he's worried about his mama back in New Jersey. Maybe he's worried about his girlfriend back in New Jersey. A lot of other things could be going on with current, and probably playing the odds those things are far more likely than anything real sinister like chemical or biological warfare. Okay, in the chem bio warfare context what could this be? Nerve agent. Nerve agent, really good. Good, so this could be nerve agent. At least nerve agent would give you some of the features of current's condition here. Now when you start to approach this on the battlefield, I tend to find that students get real confused. There's dozen different chemical agents, dozen different biological agents going through their mind, and it gets real difficult trying to sort those out. So what I like to ask students to do is envision this two by two table. We're looking at is this a pulmonary syndrome versus a neuromuscular syndrome? And then we're looking at does this present in delayed fashion or does this present in immediate fashion? So the first question is is this a pulmonary syndrome or is a neuromuscular syndrome? And how would you differentiate those two? Well you can take a stethoscope here and you could listen to his chest. So if I take a stethoscope here, I'm going to listen to this guy's chest, and if this were primarily a pulmonary syndrome, I might hear Rawls, Ronkai, a lot of congestion in his chest, but I don't hear that here. So this doesn't seem to be primarily a pulmonary syndrome. This seems to be a case of Kern's not able to breathe or he's having trouble breathing, but it's not because there's anything wrong with his lungs. It's because the muscles that operate the lungs don't work properly. And in fact if I examine other muscles, if I were to lift up his arm for example, then I would find the same thing. So I'm going to pick his arm up and you notice it just drops right back down to the gurney. So he seems to have a neuromuscular syndrome rather than a pulmonary syndrome. And you guys are exactly correct when you say that nerve agent intoxication can produce a neuromuscular syndrome. Now how would you differentiate nerve agent intoxication from something else this might be? And again, nerve agent intoxication is a chemical effect. What about biological weapons? Any biological weapon that could cause this? Anybody? Botulism. Botulism, Jackson. Good. So this could be botulism or it could be nerve agent intoxication. And to the Army truck driver, those two might be confusing. But to a bunch of highly trained medics, there are some very simple ways of differentiating nerve agent intoxication from botulism. And how would you tell the difference between between those two entities? Secretion. Secretion is good. So what would you expect the nerve agent casualty to look like secretion-wise? Wet. Wet. Absolutely. So the nerve agent casualty looks a lot like you looked last time you staggered out of the gas chamber. They're drooling, they're slobbering, snot pouring out their nose, tears running out their eyes. What would you expect the bot casualty to look like? Dry. Dry. Absolutely. Main or good. So the bot casualty, they may have a little bit of drool because their muscles of swallowing are so weak, but in general you'd expect their tongue and their lips and their gums to be very dry. So secretion is excellent. What else can you use to differentiate? Pupils. Good. So the pupils in a nerve agent casualty would be what? Constricted or dilated? Constricted. Constricted. Constricted. How about a bot victim? Dilated. So if you looked at Kern's pupils, his pupils would be very dilated. So you can use the presence or absence of secretions, you can use the size of the pupils, and then finally we talked about the neuromuscular paralysis of nerve agent intoxication and of botulism. And the type of neuromuscular paralysis with those two entities is very different. And you notice that when we lifted Kern's arm up it just flopped right back down to the gurney. So he has a flaxid paralysis and botulism would give you a very flaxid paralysis. What would the chemical agent, the nerve agent casualty look like? Well it could end up being flaxid but first there's hyperactivity. Right hyperactivity. So the nerve agent casualty generally starts out with a very spastic paralysis. He's twitching, he's spasming, he may even be seizing. So very easy to tell the difference between nerve agent intoxication and botulism based on size of the pupils, based on the type of paralysis and based on the presence or absence of secretions. But there's an even easier way and a more important way to tell the difference. When would botulism present? You saw he presented three days after this alarm went off and if you really believe that that alarm occurred around the time of the exposure, then this took him several days to present. When would a nerve agent casualty present? Immediately. And the point I like to make is made by asking you who decides whether Curran lives or dies out there on the battlefield, who determines whether he's going to do well or not do well? You guys do. Right, absolutely, you're the medics. If you do the right thing Curran might pull through. If you don't do the right thing Curran might not pull through. On the other hand, who decides whether the chemical casualty lives or dies? The casualty, absolutely. He's out there on the battlefield, he gets exposed to nerve agent, he starts having symptoms immediately. He gives himself a mark one, he may pull through. If his buddy gives him a mark one, he may pull through. But if they don't give him the mark one out there on the battlefield, chances are he's not going to make it to the 28th cash for you to have a chance at salvaging him. So this guy that he presented immediately or in delayed fashion, he presented in delayed fashion. So it's much more likely what? Chemical or biological. Biological. Right. So you've got a delayed casualty with a neuromuscular syndrome, not much else that can be other than botulism. So you see how with a couple of minutes of training, you guys can readily differentiate pulmonary versus neuromuscular syndrome, immediate versus delayed presentation. This is a delayed presentation of a neuromuscular syndrome, must be botulism. Not much else it can be out there on the battlefield. So great job. Again, in two minutes worth of training, you guys have shown that you can readily manage these types of patients on the battlefield. Tough parts going to be sorting this guy out from everybody with the flu and mono and malingering and all that kind of stuff. You know, Ted, I've always had a lot of difficulty with neurology and I think that was a great video segment you just did. And I think it showed yesterday in our clinical round segment when neither of us could come up with the diagnosis of botulism in our patient. But it might be useful for people to separate neurologic findings into two categories, those that are central and those that are peripheral. Botulism is noted for its peripheral manifestations, peripheral neuropathy, as well as its boulevard symptoms. Things like saxitoxin and trototoxin might also cause a peripheral neuropathy as part of their clinical picture. And conversely, Venezuela and Aquinas cephalitis certainly would present with central nervous system findings, namely headache and meningism. So I think you're right. Well, yeah, definitely. And don't forget that some of the plague patients and some of our anthrax patients may also develop meningesial sides and a meningitis as part of their part of their disease process. That's a good point. And, you know, one of the facts and questions we had concerned the Sferdloff's anthrax outbreak. And I might add that 21 out of 42, exactly 50 percent of the Sferdloff's anthrax victims that went to autopsy actually had a finding of meningitis at autopsy. All right. Well, great, Ted. I think it's good to summarize at this point. Now, we've talked now about patients who present either as non-specific fevers or patients with pneumonia or with a coagulopathy or with dermatological manifestations with nervous system disease or signs and symptoms. And this certainly makes this task of, you know, establishing a diagnosis and formulating a treatment plan pretty problematic. You know, hopefully, though, Mark, I think we can simplify things and clarify things when we start talking about treatment. But you're absolutely correct to imply the clinical acumen is of the utmost importance. And all the clinical acumen on the world, in the world, on the other hand, though, isn't going to be enough to establish a definitive diagnosis in every case. Well, and that's why it's important to have some competent laboratory backup. While it may be difficult at times to get that backup in CONUS during peace time, you know, when we're on the battlefield, as you know, well, you know, we really need to know ahead of time where we're going to get that support. Okay. Well, we've talked now at length about clinical diagnosis and how it's very important to make that clinical diagnosis. And I always like to use anthrax as my example. You need to treat anthrax victims before the culture comes back, before the blood culture comes back, before the PCR guys get there to the field. If you want to have a very good chance of salvaging that patient. So often, the diagnosis needs to be suspected and made on clinical grounds and treatment needs to be started before a definitive diagnosis is established. But with that said, I'm sure that most people would agree that definitive laboratory diagnosis is critically important in guiding therapy and in establishing a prognosis. So you want to have a concrete confirmed laboratory diagnosis eventually. And you want to have that pretty early on. That's again, going to help our management. It's going to help with prognosis. And it's going to help guide those guys who might have their fingers poised on the button. So in order to help us with confirmatory laboratory diagnosis, it's my pleasure now to introduce Lieutenant Colonel Eric Henshel. And Colonel Henshel is Chief of the Diagnostic Systems Division at USAMERD up at Fort Dietrich. Eric, welcome aboard. Well, thank you for having me back this year. I appreciate it. Okay, well, what kind of laboratory support would be available on the battlefield? Well, I think the laboratory support is going to be fairly limited. But the DOD is taking steps to improve that generally. You know, Colonel Henshel, I can certainly echo that. You know, when I was in Bosnia, as I recall, the combat support hospital there, you know, they had some special screening measures for things like honda virus. But some of their other laboratory support, especially, you know, the microbiology and culture capability was definitely pretty limited. Yeah, I think your experience is pretty typical, especially for the endemic infectious diseases where laboratory services have generally been de-emphasized in many cases. But I think you'll find that in theaters of operations where exposure to B.W. agents is a really high risk, microbiological services will be augmenting in the theater. This was true in Operation Desert Storm and continues even today through current operations. I think you'll find that there's been a heightened awareness for B.W. in the Department of Defense. And if you, as a medical care provider, screamed anthrax, it'd be a little bit like saying fire in a movie theater, you know? I think you'll find that there'll be a lot of responders. Okay, so let's say I think I've got a biological casualty on my hands. Presumably, I'm going to have to use my clinical judgment and I'm going to have to start therapy. But eventually, again, I want confirmation. So what do I do with my diagnostic specimens if, for example, I'm down at echelon two or at echelon three? Well, specimens are going to be forwarded to the normal technical channels that are available in a theater of operation that's fairly mature. You might find a theater army medical laboratory. The other support that may be available to your Navy EPMUs that are stationed throughout the world and in the future, we're hoping for a deployable U.S. Air Force asset that will be supporting the theater as well. If these deployable assets aren't available, those specimens are going to have to come back to the CONUS reference laboratories, either to use SAMR or to the Navy Medical Research Center in Bethesda. Okay. But the CDC could also play a role here. Well, Colonel Henshel, you know, one of the problems I've noted, you know, for those of us down in the trenches, you know, sometimes, you know, lab reshelfs invariably seem to take forever. And, you know, it seems like by the time we get them out in the field, certainly, it may be too late to make decisions. And, you know, when we do get them on time, very quickly, and in other words, you know, invariably, they're negative. And now I don't know if that's because of bugs, dying transit or what happens. But, you know, what can we, as clinicians, do then to improve the speed and accuracy of these tests? Well, the critical elements for success here is really in the collection, collecting the right sample, in the handling, making sure that the sample is preserved, and transporting it rapidly to a laboratory that really can perform the tests that are necessary. The quality of the laboratory test depends critically upon how that specimen has been handled before it reaches the laboratory. Very often, I've seen in operations where the specimen is worthless because it's, they've waited too long or it's taken too long to get to the laboratory. But the other critical component is the physician or healthcare provider must coordinate closely with the laboratory. Laboratories sometimes get specimens and don't have any idea about why that specimen arrived. And so it's important to talk to them, call them up, tell them what you have. And also, your observations are important for us deciding on what test plan we should use for how we handle that specimen. All of these things can improve the service that we give the healthcare providers. I think our audience members might be wondering what kind of clinical samples you need to be sent to the lab after a suspected incident. And to answer that before I go to you, Eric, maybe it would be useful to turn to Major Neil Wolin on videotape and to ask him for his opinions on this. So, Neil? For early agent identification from a medical standpoint, one would need to primarily focus on the portals of entry and also body parts that may be exposed to the air, to the environment. The ears, nasal cavity, oral cavity to include sputum would be good indicators of whether or not the person has been exposed. Conjunctival swabs, any hairy part of the body, mustaches, eyebrows, could be swabbed or even clipped and collected as samples. One of the important factors here is to use a type of swab that the agent can be easily removed from once it's in the laboratory to do the analysis on because you're not going to carry the swab all the way through so we would need to remove the organism from the swab and rayon swabs work work best for that. Okay, well, Eric, do you have any additional comments on clinical specimens? Sure. Well, you know, comprehensive information about each of the critical or priority agents is contained in the Book of Items as you call it or the Blue Book. I think also that that information is summarized in the student manual if I'm not correct. That's correct, I should do. Shown here is also probably is a summary of the kinds of specimens that I particularly like. I usually think of the three different kinds of patient scenarios. One is that immediate post-exposure period. That's when maybe the BIDGE unit or the portal shielding has gone off and people are healthy. What is the, what are you supposed to do? There may actually be patients showing up at your emergency center from psychological trauma maybe more than anything else. But in the, in that immediate post-exposure period we found in laboratory animal studies that we can recover anthrax at least from the nose or from the face or hairy portions of the face within about a 24-hour period. In that first, in that very first early period it's also important to take a serum specimen that we can archive and then use as a reference for later if that patient becomes ill. Once you have a patient that is acutely ill maybe is having those I don't know we used to call them flu-like symptoms. Then you begin to take what are the specimens that would ordinarily be clinically indicated. I still would take swab samples of the nose and the throat. We found some, some of the viruses begin the replication of the throat and we found that we can, we can isolate Venezuelan equine encephalitis, for example, from the throat. Interestingly, the detection of anthrax falls very quickly from, from the nose. You can't, you can't detect it after 24 hours very easily. You can detect it in feces though by animal studies and so that might be another specimen that we would want especially for anthrax. Of course, I would expect the healthcare provider also to think about the sputum in the case of plague. Urine has been a source for some of the toxins especially in that acutely ill patient. In the critically ill patient, of course, then it really becomes more obvious that there's, that, that you have a probably a patient with a known syndrome. And there you're going to rely also on blood, urine, feces, and what other, other specimens that might be clinically indicated. Okay, so let's say I get you your clinical specimens. Now what kind of laboratory tests do you use back at your reference lab to identify these agents? Yeah. You might remember from Neil Rowland's discussion talking about actually three levels of identification. We have a presumptive ID and we have a confirmatory ID and we have a really the definitive identification. In order to reach these different levels of identification, we use an integrated system of diagnostics that you samer. What we find is that no single technology is really sufficient to make a definitive identification. And so we use these overlapping technologies. Some of these are based on immunodiagnostics such as immunofluorescence assay or the enzyme-linked immunoassay. Other assays are based upon gene amplification such as PCR. Finally, at a reference center like you samered, we would use culture. And it's the combination of these things that gives us the highest level of sensitivity and specificity in our assays. At you samered, we actually demand that we be able to identify at least two or more independently derived biological markers in order to make identification. Now you should be able to do some initial risk assessment based on one of those markers. But if you were going to try and make strategic or tactical decisions on any of those tests, you might want to wait for the definitive identification. You know, Eric, you've probably heard of these. In fact, I'm sure you get a lot of calls about these, but I do as well, these smart tickets. We get a lot of questions about them. Some lieutenant down at the quartermaster bakery will have gone out and got a smart ticket at the hardware store or wherever and went around testing and he got anthrax from the heating ducts. I wonder if you could comment on the utility of those. Yeah, calling them smart tickets is probably a misnomer, but there are commercial assays available for identifying biological warfare agents, and I can't recommend any of them. None of them have been validated for medical use and that's the important consideration. Now, there are other similar assays, you may be heard from Don Bubley about the Hand Hill assay, the Immunodiochromatographic assay. That particular assay was optimized for use with the Portal Shield and BIDS units. And so it was optimized for a very particular situation and what we find is that when people use these assays off protocol, they become somewhat non-specific. The other problem with these assays is they have a tendency to be not be very sensitive. They generally do not detect biological agents at a concentration that would be equivalent to the infectious dose for man. And so there's a possibility of false negatives. So the problem is what kind of decision can you make based on that test? In fact, in the circumstance of where I've seen it use it's more likely that it has delayed getting that specimen to a qualified laboratory and that should really be the key. That's where the emphasis should be to get that really in the hands of the subject matter experts as soon as possible to make the identification. Well, sir, I think that brings up a good point. And let me ask you then if we're out in the field and our forward lab then has some kind of a presumptive ID on a BW agent, do we need to do any further confirmation beyond that level? Oh, absolutely. And that should be a message that you should have gotten from Neil Wolin in the tape segments. The medical decisions are only going to be based upon the confirmed identification, I think. Okay, so how fast can a biological warfare specimen or sample be confirmed and how fast can those results be made available to the requesting facility? You know, that's a difficult question because the time that it takes to process a sample and get the right answer depends a little bit upon what the workload is. If you have a thousand patients sending specimens to the laboratory, that's a lot different than if you have the one or two. I think you probably do recognize that. And each of the agents we find have particular, they each pose special technical problems. The other thing is that it also depends upon the biological matrix that you're sending the sample in, for example, if it's blood or feces, okay? But all that being considered, USAMRT has had some experience in being able to judge how long it takes to make a definitive identification. Generally, I can say that for anthrax and for many agents we can have a definitive identification in about 20 hours. We can have a confirmed result in about 12 hours. And certainly we can do an initial risk assessment meaning telling you whether we really think you have a biological agent in about an hour to two hours. And so those should give you general guidelines for how long it takes. That's certainly a lot better than I would have thought. Great. Well, let's say we have a positive sample then from a BW patient. Is there someone we're supposed to report that to or something like that? Well, that's a good question. And really the reporting chain for any infectious diseases is really defined. You really need to contact the command surgeon and especially if you think it's a biological warfare agent. So we use the medical chain. Now, I've had questions about whether from medical caregivers whether they should be thinking about NBC reporting and all those things, you know. And actually I have a feeling that that isn't really something I want medical caregivers to be concerned about. I really think that the real the identification of biological warfare agents in the theater really requires kind of a an integration of information. And really you'll find that the command surgeon will attempt to integrate that maybe with some report of a missile or attack or other things that were going on at the same time. And you as a medical caregiver in that frontline field hospital isn't going to be able to to see these other things that are going on at the same time. So use the medical chain. That's really really the critical critical element there. Okay. Well, Colonel Henshel I would presume that if we had a large scale either biological or chemical attack we're going to have some dead bodies around. In fact, we've seen in our scenario here today some people dying. What kind of information could be useful from those the dead bodies? Curious. It's not always what comes from the body that's important or from the patient. It's often the information that you have that's important. So if you have I know it's a lot of healthcare givers also keep their little notebooks and things like that. All of that information is very critical as a follow up to the mortality where a B.W. agent is suspected. The pathologists will be wanting to take tissues and some of the important tissues are postmortem blood for example if available. Blood is an important source of agents very often. All the bacterial agents for example cause of bacteremia eventually. Lung and spleen are obvious samples as well. Mediastinal lymph nodes could be a source of organism for example liver and other organs but I think that we don't have to think of these as this particular situation that's different from any other autopsy. Again it depends upon whatever is clinically indicated are the kind of specimens that you're going to want to take. Okay. Okay well thanks very much Eric for being here today. Now right now I want to take a moment to talk to our Air Force and Navy colleagues in the audience. We've heard a lot about what laboratory support the Army provides. So Captain Hansen I wonder if you could talk to us a little bit about what the Navy has as far as clinical specimens and as far as diagnostics to back up these detection systems. Sure. Those Navy Preventive Medicine units that I mentioned the four that the Navy has throughout the world those are deployable units and built into their capability is a forward deployable lab capability. And this has been used with some success in different operations. It is essentially a public health lab that helps us with diagnostics on things like malaria, diarrhea, hepatitis but also built into this forward deployable lab are BW capabilities BW identification capabilities. These Navy forward deployed lab elements work closely with their colleagues in the research and development command who actually develop the rapid diagnostics and so they try to remain at the essentially the cutting edge of the validated tools. These are small and light units that can be put forward and operate in or associated with a clinical facility to help diagnose patients as quickly as possible. Okay, well thanks. Colonel Bradshaw, I don't know if the Air Force does anything differently or if you want to comment on what the Air Force has available. Just a couple of comments. Of course, unlike the Army and the Marines for instance who have a very large footprint on the ground the Air Force tends to have a bit smaller footprint. And our hospital is an air transportable hospital which means we don't take a whole lot along with it. So usually our basic laboratory capabilities in an air transportable hospital are fairly limited. In that sense, for more advanced things we might rely on the TAML for instance or the forward deployed laboratories for the Navy for more advanced capabilities. We do however have a biological augmentation team and part of that is we're developing a capability called RAPIDS. We have our own acronyms also in the Air Force. We have the same infliction as everybody else. But that stands for RAPID Automated Pathogen Identification Device System. And it's basically similar to what Major Willem was talking about earlier. It's a PCR based portable system that can be used in theater to fairly rapidly say within 150 minutes from setup to diagnosis do clinical diagnostic specimens with again a presumptive diagnosis with definitive confirmatory diagnosis later at USAMRAID. But it would allow us to get a much more rapid idea of what's going on in theater for clinical specimens. Okay. Well, thanks very much. All right. I think it's now time for a well deserved break. It should be lunchtime on the Pacific coast. It's probably well past lunchtime in the central time zone and mountain time zone. So at least let us give you a 10 minute break. Now you can at least grab a cup of coffee, maybe a bite to eat and we'll see you back in 10 minutes. Well, welcome back everyone. I hope you all enjoyed your break. I think we understand now how to recognize and investigate a biological weapon outbreak. We've also discussed the different clinical presentations of some of the potential BW agents and how the lab and detectors in the field can help you make a diagnosis. Now let's move on and start to talk treatment. Okay, but first let's review some of the key concepts. Now we mentioned most of those key concepts in our 10 commandments discussion. I think though that you have to remember chemical casualty management is quite different than biological casualty management. And that's because biological agents have incubation periods. So I think it's useful to think of the average chemical incident as a hazmat incident. Whereas I think it's useful to think of the average biological agent incident as a public health crisis. The CDC is going to discuss this in more detail tomorrow. But what this in essence means is that chemical casualties present immediately. Biological casualties often present in delayed fashion. And as you saw in my little video where I had the different makeup on this makes first aid, self-aid and buddy aid much less important in the case of biological casualty management than it would be in the case of chemical casualty management. Right Ted with that in mind then let's look at treatment beyond the care an individual soldier might be able to provide his buddy for himself. Let's move then beyond echelon 1A. Now for that we've asked our colleague George Christopher Back and he's brought his doctrine with him again. George welcome back. Thanks Mark. Now to re-emphasize the first thing to remember about treatment is to pay attention to the basics of supportive care. Initial care might include oxygen, intravenous fluid and other basic measures of supportive care. So we shouldn't approach these patients any differently than any other. That's right just like you would any other patient. Okay so don't forget your ABC's that you learned back in BLS. Exactly. Okay George I think both you and I agree that specific antibiotic therapy is a no brainer if you know the agent and its susceptibilities. Right. Rational antibiotic therapy involves using a drug that's active against the specific agent and ideally has a narrow spectrum low toxicity and low cost. Now that may be different than what we've you know some of the drug reps might be peddling these days you know to use the biggest gun agent available that's got the best spectrum. Right. Gorillicillin and Cephachillum all have their place but in pediatrics if we have a bug that's sensitive to Kool-Aid then Kool-Aid is the drug of choice. Now that's not always so easy to institute on the battlefield. First of all the patient on the battlefield presenting and this is true in civilian conventional medicine as well they don't always present with a label tattoo to their forehead telling you what they have what bug they're infected with what its sensitivities are. So because of that because we're going to see casualties before we know what's going on I think it's helpful to talk about syndromic based therapy. Right. So in a biological warfare scenario it might be appropriate to cover multiple agents initially before we have a specific etiologic diagnosis. Great. Well you know we have to remember that on the battlefield multiple agents could be used at the same time. There may be some rationale for the notion that if you find one agent there might be more it might make sense then to use a broad spectrum treatment until we can establish a definitive diagnosis and rule out multiple agents. So one of the bits of good news about biological warfare though is that many of the bacterial diseases that we talk about in a BW context are susceptible to some very common antibiotics. For example doxocycline can be used to treat anthrax it can be used to treat plague and it can be used to treat tularemia, brucellosis and Q fever as well. That's great. Well George let's say then you know based on your epidemiology that you think you've got a BW attack going on you know but you don't yet have a diagnosis. What would you recommend for empiric therapy? Well Mark that's going to depend on the situation but you can go a long way to arriving at a good decision based on the clinical syndromes that we discussed earlier. For example if patients start coming in with flaccid paralysis they might have botulism but not anthrax plague or other diseases for which antibacterial drugs would be indicated. Okay so let's talk first about the patient presenting with pneumonia. You've got a tight cluster of cases of pneumonia based on the evidence you think it might be a little deliberate you think it might be a biological attack. Maybe you do a sputum gram stain that gram stain is negative or it's equivocal or you don't have gram staining materials available at the moment. What do you do then? Right well the differential diagnosis of pneumonia in a biological warfare scenario is going to include plague, meliodosis, tularemia, brucellosis, q fever as well as some of the toxins. Now in that case I'd consider a combination of ciprofloxacin plus an aminoglycoside either streptomycin or genomycin. This combination is going to give first line bactericidal therapy against the treatable but potentially lethal agents of plague and tularemia. Now based on in vitro susceptibility it will at least buy some time against meliodosis, brucellosis, and q fever. Ciprofloxacin plus doxycycline would give a similar spectrum of activity and would be a rational alternative. Okay. Yeah and one of the other things is that that drug combination would also be useful against anthrax. Now anthrax keep in mind of course as we've mentioned yesterday does not cause at your garden a variety of pneumonia it actually doesn't cause pneumonia per se at all it causes a mediastinitis but those patients may present with respiratory symptoms therefore they could potentially be confused with pneumonia especially if you know sometimes happens you don't have an x-ray machine handy or it's not working. So what about the patient then who comes in just with a nonspecific febrile illness? Well the differential diagnosis would be even broader would include anthrax the viral agents as well as some of the endemic naturally occurring diseases but if you think you're in a biological warfare scenario you've got to cover the treatable diseases namely the bacterial diseases that lend themselves to antibiotic therapy the combinations of ciprofloxacin plus an immunoglycoside or ciprofloxacin plus doxycycline would still make sense Well I agree and then you know something like Venezuelan equine encephalitis also called VEE you know can cause a nonspecific fever and antibiotics wouldn't help however you know if you've given a patient a short course of antibiotics and later you make that diagnosis of VEE you know those antibiotics aren't going to hurt that patient anyway Now Mark I know you don't want everyone out there in television land to go around thinking they should treat everything with antibiotics and I also know that they are going to have a copy of their blue book in their pocket in fact and I think I want to make use of this blue book you're not going to remember which diseases need which antibiotics when you're out there you're not going to remember all the specifics of antibiotic therapy and again that's why you have this blue book BDUs have two hip pockets for a reason one was designed for your blue book one was designed for the chemical people's green book Colonel Madsen who was in the audience yesterday has put these into many of your hands now as I asked him my scenario who decides whether the bio-casualty lives or dies well it's you it's you the medic out there if you do the right thing in short order maybe the casualty lives if you don't do the right thing maybe the casualty dies now who decides with the chemical casualty lives or dies well as you heard in our scenario it's the casualty if he doesn't give himself as mark one antidote in short order he never even makes it to medical care so what I would recommend and unfortunately Colonel Madsen is not here to hear this but what I would recommend is get rid of this steal your buddy's copy of his blue book and put two blue books in your pocket next time you go to war great Ted well since everybody's going to be forever forever more carrying two copies of that blue book around for reference you know I don't think we need to go into the specifics of therapy for specific diseases in great depth you know I agree Mark we covered that at least for five agents yesterday but the bottom line is once you have a definitive diagnosis this is a no brainer choosing proper therapy is a matter of looking it up but that's not to say you're going to save everyone you're still going to have casualties but you're going to do the right thing if you make a diagnosis in short order remember ultimately your therapy is going to be guided by sensitivity data as well well Ted you know I'd like to play devil's advocate advocate here let's say someone loses that blue book or let's say they've forgotten it or you know they've ordered George's FM 8-284 and that hasn't arrived yet lo and behold and George you know what other resources are out there for the audience well the worldwide web is an excellent resource we've already mentioned the Army Surgeon General's website and there's certainly others out there the course packets include a list of very useful references great okay well let's take this concept of empiric treatment treatment one step further Ted let's say I'm a special forces medic and I'm working under covert conditions I've only got a couple men with me and I've got no doc and I definitely have no lab with me we get slimed by a bio attack and all I've got is my aid bag what can I do for my guys well Mark I think even in the most austere of circumstances with no diagnostic aids available other than your keen sense of clinical acumen you can still make some very intelligent decisions and to help those grunts down there at echelon one I think it's useful to construct a matrix in your mind and I like to think of this two by two matrix where I divide casualties into those that present in immediate fashion and those that present in delayed fashion and then further more I divide them into those that present with primarily pulmonary symptomatology and those that present primarily with neuromuscular symptomatology now I think it's useful to go ahead and start filling in that matrix and when you start to fill it in there are a lot of potential agents we talk about in this bio course the chemical people talk about a lot of agents but for many of those agents there's no specific therapy available nor is there any specific therapy required for many of the casualties we're talking about supportive care is the answer so let's throw out for a minute those diseases that require only supportive care what you're left with then are actually very few diseases indeed and you can see them here in the matrix the only thing that immediately causes neurologic casualties is nerve agent intoxication botulism is in a category by itself cyanide and then finally several of these infectious diseases now you're probably not going to have botantotoxin down at echelon one you may not have a cyanide kit but you're going to have nerve agent to antidote and hopefully you're going to have antibiotics and the beauty is as I discussed earlier doxycycline actually covers all of these infections pretty well now as an infectious disease doc never would I want to give you the impression that you don't need to think about the patient you don't need to make a definitive diagnosis you can just give everybody doxycycline but on the other hand at echelon one before you know what's going on if you think of these four categories I think you can easily see not much fits into each of those separate categories and each of them has its own specific therapy right we need to remember again that many patients including those in the pro-dromo or early phases of anthraxin plague will present simply with an undifferentiated febrile illness for that reason I'd recommend that patients with fever in a biological warfare scenario be treated just like those with pneumonia namely with broad empiric therapy Ted you talked about this algorithm this two by two matrix is that available to the echelon one medic right now well mark it's available through this course obviously we've written some recommendations along these lines so hopefully they'll be published in military medicine soon you know I wonder that might have been the rejection letter I saw in your mailbox the other day it probably undoubtedly was knowing my career I want to remind you though for the for the last time those of you out in the studio audience there's certainly no substitute for a good laboratory backup and for a thorough well planned medical work up and I caution you this algorithmic approach is not a license to stop thinking about the patient that's key as soon as the patients who are being treated empirically can be re-evaluated they should be evaluated by more experienced medical personnel appropriate laboratory studies should be done and then the therapy modified accordingly you know you know there's one thing here that bothers me about all this question you know discussion of therapy and that's availability you know when I was in Bosnia I can't imagine that my buddy Bruno who was in the pharmacy there had that much cipero on hand you know I understand Mark last time I was deployed I think we had enough doxycycline to treat the mess sergeants a chlamydia infection but we're trying to do something about that problem and as I said earlier DOD feels your pain in the army when we go to war we speak of sets kits and outfits those are the component modules that we take all of our equipment to war with and those sets kits and outfits have some doxycycline and ciprofloxacin in them but certainly the amount is limited there are specific chemical warfare set kits and outfits but there are no bio sets kits and outfits as yet however the joint readiness clinical advisory board is meeting they've developed task time treater files looking at recommended ways to treat these various diseases those task time treater files will drive the logistics train and ultimately these drugs will be incorporated in our go to war sets kits and outfits I think you know the wheels turn slowly it'll be a few years before they're filtered down everywhere but again we're aware the problem and hopefully it will be fixed long before you ever need it great Ted thanks all right now at this point I think we've pretty much beaten diagnosis and treatment to a poll so let's go back to the field and see if our buddies at the four or fifth cash have have come up with the diagnosis yet table two and stop breathing I need help cold blue cold blue cold bed two cold bed two I'll take it I'll take it all right let's hook up the monitor and charge up the defibrillator okay this patient still has a hard beat but he stopped breathing bag him let's bag him okay he's going to need intubation let's get him two here okay I'll tube him okay let's get him two good okay put that bag give him a couple good breaths here okay we're in we're in all right hook them up to the ventilator okay I'll I'll take over now great great damn what's going on here the patients are dropping like flies we don't have the slightest idea what's going on I know the labs went in when we as soon as possible absolutely great okay Borgard Borgard Borgard okay he's got a 36,000 white count with a left shift he's got gram-negative rods in his sputum Dr. Cooper this young soldier has gram-negative rods in his sputum I mean what have we got going on here Klebsiella E. Coli this doesn't make any sense I don't know but if this is a BW agent then that narrows a differential diagnosis quite a bit let me take a look at that stain damn it these organisms are bipolar staining you could have mnemonic plague here do you say plague sir plague it's okay we can treat we're gonna treat that way streptomycin streptomycin or genomycin would be a suitable alternative for the staff we need everybody masked up here and doxycycline prophylaxis for everyone who's had face-to-face contact and we need to initiate a case contact investigation with all unit members great I need a contact division surgeon right away they need to know that we've got a mnemonic plague outbreak here we need to check with the pharmacist right now we got to get these antibiotics started let's move out okay okay so it looks like the assumption in our scenario is that we're dealing with a plague outbreak but based on the information you have is there anything else this could be anything else this could be tularemia tularemia right remember we mentioned tularemia was a plague like illness gram negative rod on the sputimate can look plague anything else milioidosis again another gram negative rod disease causes pneumonia talked about in a biological warfare context this could be viral could be influenza and the gram negative rods could be a red herring well let's review a little bit we've talked about ways to protect against plague we can divide those ways into pre-exposure and post-exposure prophylaxis when we talk about prophylaxis we can talk about immuno prophylaxis versus chemo prophylaxis so again you have this two by two matrix is pre-exposure immuno prophylaxis post-exposure immuno prophylaxis pre-exposure chemo and post-exposure chemo prophylaxis but beyond prophylaxis beyond the antibiotics and beyond the immunizations I think it's also useful to talk about physical means of protection now plague remember is one of the few biological agents that is actually contagious person to person and I think there's the perception out there amongst many laymen and even amongst many medical people that the words infectious and contagious are synonymous in fact they're not most of the diseases we talk about in a biological warfare context are infectious but only two of them are contagious again plague and smallpox so here's one of the two perhaps that is contagious and now we want to know about physical protection of these agents Mark Ted and and basically you've brought up a good point here there are there are only those two agents that are contagious from person to person one of the benefits at least is that we do have prophylactic measures for plague and and that's doxycycline and then we can vaccinate people early for smallpox of course if we have enough vaccine as was discussed yesterday I think Mark we already discussed yesterday also that plague's a worse weapon for the battlefield commander in some respects because of its contagiousness right and prophylactic treatments are available from any of the agents that are not spread person to person for example anthrax and tularemia you know prophylactic treatments for these diseases that we're talking about are listed in your student manuals now remember you can't get the diseases that George has mentioned from your patients if you're a ground zero and an anthrax weapon goes off then you perhaps are in trouble if you didn't have your mask on and perhaps you need prophylaxis in fact definitely you need prophylaxis on the other hand if you're a medical care provider you're taking care of anthrax patients you're not at risk of contracting anthrax from your patients you know Ted don't forget that when it comes to prophylaxis you're going to need to find out who actually needs it now in a full-scale war that's going to be tough and we talked about this of course earlier in the epi epi segment but hopefully you can use your epidemiology to know who to prophylaxis while they're still in their incubation phase now this will likely be people like other unit members co-workers you know people who are basically in the same area simple for an epidemiologist is a shoe with a hole worn through it those PM people will be out there wearing through their shoes you know while they're hunting on these people okay well George I'd like to thank you once again for being here today now as our scenario at the 405th has unfolded it looks like they're dealing with an outbreak of plague and we need to talk about protecting the medical staff with infection control measures again prophylaxis and immunoprophylaxis but as medical care providers we have to be aware that our patients might bring contagious diseases into our facilities and those contagious diseases like smallpox and pneumonic plague could infect other patients and god forbid the medical staff we can't do much for our patients if we're all ill as well now we've already discussed the medical prophylaxis with me to discuss protection is Major Don Nurges you may recognize him from our audience yesterday he's going to help discuss the importance of infection control John is a research protocol nurse at USAMR he's also the officer in charge of the aeromedical isolation team as well as head nurse in our BL4 care facility welcome John now John it's obvious that I want to avoid passing out prophylactic drugs to everyone on the medical staff every time a patient with plague comes in if I can do that so is there anything I can do to avoid doing that sure first thing don't panic but don't take it too lightly either something else make sure that your both pockets are filled with that book got that covered you know nurses doctors medics we we like to feel that we have control over all the situations in the hospital and in this case the BW scenario we do you know as team leader the aeromedical isolation team I have to ensure that we train for the worst case scenarios the most out of control scenarios well John what is the AIT can you tell the audience sure the aeromedical isolation team is capable of transporting patients with really highly infectious diseases plague smallpox and even worse diseases that we don't know what they are really it was designed for the scientists in the field who might catch their experiment so you know we train for those worst case scenarios and in many ways training that way is easier if you know you have a highly contagious disease you can treat the patient accordingly you know it's like the difference between you know standard precautions we all know what that is and then contact precautions if you know there's an infectious process that could take you or your crew out you'll take additional precautions you know we have these negatively pressured HEPA filter at high speed low drag stretchers but the AIT also trains with standard and contact precautions because they work you know good techniques like gowns masks gloves are usually enough to handle most infectious diseases you know because of where I work I'm at USAMRI and I'm in the know you know BW events scare me more than a lot of people because I know a lot but I also know that there's a lot you can do to protect yourself and still give excellent patient care so I guess you know take home messages understand that handling BW warfare patients is no different than handling any other infectious disease patients we have excellent old school established infection control procedures which really work well they've worked for a long time you know I call them BWABCs all right John why don't you tell us about what some of those ABCs are well standard precautions are required for all BW agent casualties and for most agents that's fine that means you use a gown gloves face mask eye protection if you're gonna any procedure which might splash blood or body fluid and this applies whether you're in the field fixed medical facility and it applies for all your patients not just BW casualties but any infectious disease patient and once again any patient with an unknown infection you know those favors of unknown origin well I'm sure you know beyond standard precautions there are transmission based precautions and for those of you out there in the audience there are airborne droplet and contact precautions and airborne precautions in general are the precautions we'd use for smallpox droplet precautions for pneumonic plague great you know and some diseases that present primarily with cutaneous manifestations can be handled with the contact precautions that Ted just mentioned the BW disease that come to mind are cutaneous anthrax and bubonic plague I realize though that you don't typically think of a BW scenario causing those types of illness presentations unless in the case of plague for example our adversary were to try to spread the disease with infected fleas okay well John let's say we're dealing with one of the contagious biological warfare diseases smallpox or pneumonic plague how would you propose to isolate casualties from one of those diseases well smallpox ideally you want your patients you know in a negative pressure isolation because it requires airborne precautions and it's so contagious when in when you're in the room you want to wear a HEPA filter respirator and ideally you and your staff have been vaccinated before you were allowed to care for the smallpox patient all right well let's uh that's smallpox how about the patients with pneumonic plague well then we use droplet precautions which means you do standard precautions put the patient in a private room use a surgical mask if you're going to be say three to six feet of the patient great now I don't think we need to go into detail about the mechanisms that spread then you know in the droplet sizes with those two diseases because those are those are pretty much discussed at length yesterday with Ted but John you know this is all great you know this is wonderful if we have a nice facility and we have all these private rooms or negative pressure isolation rooms they handle you know a whole boatload of plague or smallpox patients but what about that guy that poor doc out there in the mud or he's in a tent what's he going to do and you know and if he's got a mass count going on to boot well as you heard to preventive medicine officers say in this scenario you know you have a number of patients they got a similar illness you can cohort isolate them together in the same tent or same ward and it's you know if they all have the same disease they're not going to give each other the same disease they already have well that helps certainly protect the other patients and the staff from getting the disease but it also can be helpful from a logistic standpoint as well I think exactly if we need to use gowns or you know any kind of materials in a field setting they can be dawned outside the ward where all the patients will be and this might help save some of those expendable items gowns and gloves and masks you know remember in an austere setting you know your supplies may not be shipped in daily so it's not unreasonable to consider assets in relation to patient care but certainly don't hold back if you need a new item you know a new gown or a mask go get it John you know I'm wondering if some of the folks out in the audience might be asking whether you know does our M40 mask protect us from either a contagent patient or a BW release what's the answer absolutely if we're you know wear it right and make sure it's on before the exposure all right well let's say then we're under you know if we're under high threat of an attack our medical providers might have to be in mop gear I would suspect it's probably pretty tough to take care patients in mop gear isn't it absolutely training you know it's nearly impossible to do a good patient assessment or you know a good exam when the care providers wear mop gear you know it's even worse when the patients in mop gear as well so what's the answer well it brings up a subject of collective protection they call it call pro basically it's new items in the arsenal that are being fielded positive pressure HEPA filtration systems that in effect give you a clean environment you have to use standard and contact precautions inside but you wouldn't need to wear mop gear while you were taking care of these patients and it'll significantly improve your ability to do assessments and treat okay one of the other diseases that may require special precautions are the viral hemorrhagic fevers and again for the audience members out there we talked about standard precautions and transmission based precautions there are airborne droplet and contact and I think it's useful to keep in mind airborne for smallpox droplet for plague and contact for viral hemorrhagic fevers now John you are our head nurse at the a slammer our own you know BL4 patient care facility at UCambran you know if you had a patient in there with who had smallpox let's say you'd probably take care of him in a spacesuit so this all this talk is great about you know standard precautions but you know you're using a spacesuit at UCambran why are you trying to tell that poor guy out there in the mud that it's okay for him to do something different well mark I'm not really sure either we like to look like cyanotic Pillsbury Doughboys or we just look so good in those blue suits but I think it has to do with the level of care and the ability that we have at UCambran we have the luxury the flexibility the time to make preparations and take precautions that we can use our blue suits for we ensure the providers don't become infected and that slammer remember was built to handle miscellaneous lab infections you know in the field you have to use the best protection you can under the situation and with proper use of standard precautions and transmission based precautions care providers just greatly diminished their risk of catching or disease from their patients and there's good evidence actually that field expedient measures are adequate blue suits are not necessary for effective patient care and I think to get a perspective on that it's useful to think of the Kikwit-Zaire outbreak we talked about that a little bit yesterday the CDC was called in to assist they went in they didn't take any cure they took simple garden variety hand washing gowns and gloves and the epidemic came to a screeching halt I think you also have to remember that the slammer is a two bed unit so if you've got two patients that need care there we're happy to help if you have more then that's beyond our capabilities yeah right and here's really the take home message you know as nurses medics and physicians we're trained to take care of patients relieve their suffering help them get better but we can't help anybody if we become a casualty ourselves we also can't help our patients if we're so scared that we give poor care and we don't take actions based on those fears yes I know it's scary but there's an awful lot we can do standard precautions contact precautions those precautions really do work for most agents and then one final point that I'd like to make you know when you show up in a blue suit or space suit as far as I'm concerned you can just see the patient's eyes get wide with fear you know it's important to anticipate that and the best way around that is you have to communicate the best you can to your patient to try and take some of that fear out of there great thanks John on that note we'd like to thank you for joining us here today on stage now you'll still get to see John as he returns to the audience here shortly now let's go on back to our colleagues there at the 405th cash and see how they're doing in handling this BW attack sir sir may I talk to you the nurses in the medics are exhausted they're also scared do we need to decontaminate the patients or the ward no definitely not they're already on definitive medications we don't have to do anymore but sir we need to do something otherwise our personnel are going to become casualties well I understand that perfectly but what do you suggest we do well I'd like to call in the chaplain he could come and debrief our people about the biological incident well that's an excellent idea and besides the chaplain help our people vent their frustrations and and help them over the crisis that they're involved I'm also worried because we're really stacked up back here I'm afraid our personnel are really going to get burned up before much longer unless we move some of these casualties out of here well you're right we'll have to call the medevac people remember they're already on excuse me excuse me hang the phone I'm the exo second battalion half a charlie company is missing I have no idea where they are I need to find out where these troops are we've got a lot of work to do we've got a lot I understand sir we will get to with you as soon as we can we're very busy right now if you can just be patient you busy be patient you busy what do you think I'm doing you're preparing for Sunday School I've got the serious business going on here we got to get that's not look here major you're bothering my chief nurse we're very busy here we've got a crisis now you sit put your tail in that chair and when we're ready for you call you understand now where were we we've got about five dead in our temporary more what do we do with them now okay put them on body bags call the s4 maybe they can get medevac to take them out of here in the meantime I'm going to be back on the wards okay well in that scenario we've seen a lot of fear confusion and disorganized behavior in situations and you know in this situation and we've also seen it of course with situations involving bioterrorism there's no doubt we have that potential in the field you know in a bw attack fortunately we have with us today dr harry halloween welcome sir and he's a psychiatrist from the uniform services university of the health sciences and he has a specialty in human response to mass disaster situations well once again sir welcome and as you can see from our scenario we've got personnel who are worried they're arguing they're pulling rank it's really not a pleasant situation what's going on well number one I think it's pretty much what you expect to happen in a situation where people are suddenly confronted with high demands they're experiencing deaths of patients actively on the wards they see failure around them they know the shorter resources they're wondering what the diagnoses are and so they're displaying the relatively normal behaviors that you expect to come forward in that circumstance and the fact that they're normal doesn't mean that they aren't disruptive the way you manage such behaviors in part is by preparing and the kind of training and getting through this course and going through various exercises what you do is you prepare yourself for these events so that some of this if you will expression is there but let's face the fact that the arousal that goes along with the situation is going to produce some of that behavior in any case so we ought to be prepared to manage it and handle it what about the triage situation I don't want these psychologically affected casualties gumming up my triage system as I'm attempting to deal with conventional injuries chemical injuries biological injuries in in fact triage which I think is the heart of this is one of the things you're learning to do I'm learning to do it smoothly so that it works is one of the ways you're going to be reducing stress and of course one of things that's going to be happening here is the people who are emotionally upset even as it was just pointed out by the person who's just speaking isn't just going to be the people who are just the flakes but also the people who've got the infections they're going to come in emotionally upset too so in the triage situation you're going to have to be very clear about what you have to do medically because if there's any point I want to make about reducing stress in this situation that we've discovered again and again in disaster situations providing upfront excellent systematic medical care and making sure that people know they're getting that kind of care that's the way you get rid of lots of these fears and other things on the other hand for people who aren't don't meet the right definition for our case definition that we've been talking about here those people you may want to put aside have them managed offline not by these folks because you've already been seeing evidence that you're overloaded so why do you need more overload? Right, right What about panic amongst my own troops? I don't want my own troops being affected as I'm requiring them to help me care for these patients anything I can do about that? Well let's talk about panic first because I think that always gets to be a confusing and whether it's your own troops or the folks coming in the one thing that you have to realize is that panic is a rare phenomenon particularly among anyone who's trained sometimes you'll see panic as we saw when the machine gun was introduced in the 19th century or when the flamethrower was introduced in World War I or the utilization of gas the first time but not the second time gas only produced panic the first time people were exposed to it and now if we look at what happened at the Amshurikyo attack in Tokyo panic did not occur people were scared but they went to doctors to try to get diagnoses to behave in systematic ways with regard to this you did not see what is technically defined as panic and I think we have to think about the technical division here which is to lose one sense of one's kind of work role and rather go to a non-specific role in which escape is your primary activity or total inactivity and paralysis there now with regard to your own troops what you've done with them as you've trained with them you've prepared them ahead of time that they may have to deal with this kind of circumstance and you begin to convey to them that you're going through a systematic process in this case that conveys to them that there are going to be ways they can behave that are successful and that's one of the things here that we have emerging leadership principles you really need to be a leader in this circumstance to convey that what they're doing is right and if it isn't correct it okay what about the acute psychiatric casualty how do I manage that casualty in an austere environment the critical thing number one is as simply as possible do it up front do it quickly and what you're going to do with that casualty is in so much as they're upset or the rest of that get them on give them apply to everybody who's under this stress some rest and replenishment let them go to a circumstance into a place where they can talk to somebody and maybe have a conversation about it but basically get the people who are the psychiatric casualties and assign them jobs one of the critical things and the acute situation is to give people active roles to do things one of the things you ought to be prepared to do in this circumstance is in fact what do you do with the extra help that comes from the people who come in who don't have the disease what are they going to be doing you're going to need help you might as well start preparing to use them and that's particularly applicable to the military situation where we can really prepare for it and in the civilian situation it's even more critical where in fact there'll be numerous agencies responding and each of them may have to have ways of bringing people on board and managing them and directing them about what they can do that's useful in that circumstance we can see that in Oklahoma City we can see it in other circumstances where this went on where the agencies really were prepared to say yeah we need you to do this and there's a lots of hauling and pulling and simple tasks to do so Dr. Holloway are there chronic problems that we've seen with some actual incidents if so are there ways we could prevent those absolutely there are some chronic problems and yes there are some things we need to prevent them over they talked about some of them one of the principal things we can do to prevent them is we can communicate how to respond effectively in this circumstance how to respond effectively to biological attacks how to manage the patients effectively etc that's one way and by the way from the doctor point of view take really great care of the patients because one of the groups at most risk are the people who actually have the disease they're really at most risk so if we take good care of them that's great another thing we can do on the chronic side to prevent the chronic problems is to not put people in situations where they're chronically helpless in this circumstance but again want to talk about what I want to talk about before restore their autonomy restore their health and get them some role now one of the things you also need to do is not apply psychiatric diagnoses in this upfront situation because labels given idly in this circumstance or diagnoses given idly are as dangerous to those who aren't sick as they are to those who aren't sick so we must be very careful about that process because it will end up with a misattribution of illness and chronic problems down the line finally there are going to be some people who still have chronic problems and those that's the place where your psychiatrist can follow on in echelon and care in this circumstance that can be done offline it's not a part of your acute response but that can be followed up and diagnoses need to be made of the post-traumatic cases or the other cases can be made and care can be given and appropriate therapies introduced but phasing your response and recognizing it the first thing you're doing upfront is preserve the person's health that's going to be really critical Dr. Holloway for we have a lot of first responders in our audience today and for the first responders out there are there any special issues that they need to be made aware of? Well there are two I think and you've already talked about kind of one of them with regard to the biological warfare but let me start off with the first kind of biological scenario where somebody says there's a device hooked up to a a blower at a building and there's a suspicion that it's blowing anthrax throughout the building now in that circumstance what you're going to have is a group of first responders coming to that site and we know from the first responders again in Tokyo that some of those were the bravest folks and there are also some of the people who died because they tried to remove the sarin from the actual site and they died of the sarin poisoning that's a critical kind of preparation that people need to have that is how to protect their safety how to enter that environment and feel safe and how to make the distinction between what you've made here because I've done several exercises in this area between infectious and agents that are contagious that really is important then they have all of their safe behaviors and we also as we bring them into that circumstance we're already prepared to rotate them give them time for rest let them have so that we don't get caught up in what I always think of as the mash syndrome remember the television show mash where doctors never worked in shifts at all they just operated all the time well if you ran a real mash that way it'll last for about 72 hours and then you can just wipe it off the map so you've got to rotate the task of these guys going into it but there's another group of first responders particularly in biological warfare that must be prepared as first responders they're called primary care docs because particularly if you have a terrorist event a civilian community the first person the person is going to go to with all these illnesses these fevers these nonspecific things that you've been talking about first thing they're going to go to is their ordinary doc and that person must be prepared for their role as first responder and they must make all of these same distinctions and they must know how to activate things in a systematic way okay so if you had one overall message to leave with people today what would that message be the message would be number one put through put together scenarios that are realistic play them out realistically put together plans and play realistically if you're going to bring stress management teams into this kind of area play with them up front having a strange psychiatrist show up in your phenomenon that you've never seen before is not going to work number one because they've got to know about infectious disease control that you've been hearing about they've got to know about these illnesses too so integrate all of your care but then finally just one last point I would say that don't forget that our job is to restore the autonomy of the patient get their health back and going and make sure that we've systematically prepared to minimize the damage that the bad guys want to do in this circumstance well that's useful information Dr. Holloway I want to thank you for joining us here today I think that pretty much gets us through what we wanted to cover today we hope you found the issues that we've discussed useful and interesting and most of all helpful for you if you're ever faced with a biological warfare attack and hopefully none of you will ever need this training but before we move on to questions from you in the audience let's go ahead and conduct a short review session well everybody today we took you through a BW scenario in the field remember those 10 Commandments we talked about at the beginning well as we progressed through the day to day we touched on each of those although we may not have specifically mentioned them at the time now in this scenario we started off with a mass casualty situation and we discussed biological weapon triage issues and then as things began to look like an outbreak was occurring we talked about surveillance issues outbreak investigation and epidemiologic clues to biological weapon attacks okay as the personnel in the 405th cash began to piece things together we moved on to diagnosis to treatment to prophylaxis and to infection control issues and finally we ended up with how to deal with the psychological aspects of one of these situations well I want to thank you all for joining us today we've certainly enjoyed the opportunity to present this information on how to handle a biological warfare attack on the battlefield we hope you found it useful tomorrow the CDC will be hosting the program which we which they've produced the topic will be bioterrorism for those of you in our audience who are non-military you may find it directly more applicable to your needs and for the military personnel watching and especially the National Guard we think it's useful for you to know how the civilian sector functions in case you need to help out in a large bioterrorism incident now don't forget you can receive continuing education credits for each day that you watch this broadcast as long as you take the test remember wait to take the test until you're done viewing the days of the program that you intend to view and with that I'll say good afternoon good afternoon Surgeon has requested I come to commend this unit for an outstanding job your quick recognition of biological incident as they've countless lives I'm personally very proud of all of you good luck when your next assignment the president will be awarding a special citation for this unit