 I am talking about something that's never been part of this course, and that's chembioterrorism, and I'm going to attempt to talk from both the chem and the biosides of the house. This is an experiment for us. We've never included a block of instruction on this material before. At this moment, or a few minutes from now, over at RID, your counterparts will be getting a rather similar block of instruction from Colonel Ed Eitzen, who clearly has been doing this more than anybody in the faculty of either of the two courses. I've only been here relatively short time. Colonel Eitzen's really been doing this nonstop since, I think, 1992. And why have we decided to include it? It's not really part of the mission, either of the Institute of Infectious Disease or the Institute of Chemical Defense. If you look at our mission statement, we train military professionals like yourselves, and we do research. So why do we care about terrorism? The answer is pretty obvious. We are told by our hires up, by the press, by Congress, by everybody that the terrorist threat is probably greater on a given day in this country than even the military threat that we face from foreign adversaries. We've already seen it attempted in New York City, as I mentioned, the World Trade Center bombing. And if we had any lasting doubt, the Tokyo subway attack in 1995 certainly brought that home. And, of course, Larry Wayne Harris was just arrested, I think, only four weeks ago in Las Vegas and accused of potentially trying to build anthrax weapons here in the United States. But then you might ask, well, why do we in the military have to care about that? Isn't that a law enforcement function? And the answer is, well, yes, it is, but we've been doing this a lot longer than they. And when all of this started coming down in the 1990s, people in the FBI, people in the Congress and so forth, they started saying, who's got the expertise? And guess who? It really was only the military. Almost nobody was doing research on this except the military for the last number of decades. So that's one reason why we talk about it. And the other reason is even more germane to you folks. I am about to show you that pretty much all of you, I would wager a good amount of money that at least 80% of the people in this room are actually in line to receive chem, bioterrorist casualties, totally exclusive of any wartime role you may have as an active duty or reservist military member. How many people in this room are active duty military? The vast majority. How many of you who just raised your hands are not affiliated, either full-time or part-time with a military hospital? No one. One, two, three, four people. Five. So all but five of you automatically are part of the National Defense Medical System, which although it was set up for wartime casualties, can be activated in case of domestic, biological or chemical terrorism. Now, those of you who are not active duty military, how many of you are there? Do we have too many reservists in this group? We have only two, three. Okay. Are you hospital-based in your civilian roles? How many of the three of you are hospital-based? One. You, sir, I know, are connected with an academic medical center. And you are what, Fleet Marine Force? Okay. I think I can account for all three of you. The civilian community doesn't realize that it's in line for this. One being, of course, if you have it in your backyard, but even if you don't have one of these things going off in your backyard, the National Defense Medical System may deliver these patients to you. I will tell you a true story which exemplifies this. During Desert Storm, I didn't go to Southwest Asia because I was back doing a fellowship. I was a fellow at the Hospital of the University of Pennsylvania, which is a large academic medical center, which is particularly well-known for its neurologic expertise. It is one of the largest departments of neurology in the country. And it's located across the street from the Philadelphia VA Medical Center, and it's located only about three miles from Philadelphia International Airport, which at the time was the Air Mobility Command Airhead for the Eastern United States. Isn't any more of it, it was then. And, you know, the hospital is going about its business and we're reading the news like everybody else. And one day, the chairman of the Department of Neurology, Dr. Don Sutterberg, calls me up and he says, we have to have a meeting with all the residents and I want you there in an hour. Fine. Walks in and he's carrying a sheaf of papers this thick. And he says, I've just come from a meeting with Dr. Kelly, the chief executive officer of the hospital, dean of the medical school, and the chairman of a couple of departments. Guess what, guys? We are a National Defense Medical System hospital. Nobody ever told me that. I've been the chairman here for five years, but we are. Not only that, our service, the neurology service, is listed as a receiving service for war casualties because we're supposed to know all about nerve gas. And he turns to me and he says, tell me about nerve agents. You're the only person in the entire department who has any connection with the military. Well, I had not had this course at that time. And I remembered all the stuff that they had taught me in Officer Basic, which wasn't a lot. In fact, what there was, I had largely forgotten. It turned out in this enormous department of neurology, I was the only person who had ever had any instruction on them. And that chief of papers was what they had just given him. Why does the hospital have a connection with the military? Because they get money. Hospitals in this country are paid to be members of the National Defense Medical System. So what that tells you is that there are a lot of civilian hospitals out there that are going to be shipped these things, whether they really want it or not. And I'll give you another example of how this can hit you. My friend, Lieutenant Colonel Jim Knowles, is the head of, or was at the time, the head of the Aeromedical Evacuation Squadron at Grand Forks Air Force Base in North Dakota. And he was preparing last year to go off to Wilford Hall and do an ophthalmology residency. In fact, he had started to pack up his house when suddenly every hospital in Grand Forks closed because of the floods. Grand Forks Air Force Base Hospital went from 12 beds to 500 in one week. And he, as chief of the medical staff, because he was the senior physician, found himself in the process of shuttling patients back and forth, getting all the ICU patients in Grand Forks Aeravac to Minneapolis, St. Paul, and so forth. And this simply got dumped on the Grand Forks Air Force Base Hospital because all the other hospitals had been closed. Well, what would have happened if that hadn't been a flood, if that had been, say, a mustard exposure, which essentially rendered the small area of Grand Forks where all the other hospitals were located uninhabitable? Grand Force Air Force Base would have been the only hospital left. The reason that it became the receiving hospital is that it was a little bit far away from the city and it was actually on higher ground. So we're all online for this. And that's why when actually Mr. Hettinger and Ms. Pike and I came to the other members of the faculty of both institutes and said, let's do a terrorism block, they all said, yep, it's overdue. So that's why we're going to spend a little time talking about this. Now, I'm really proud of this slide. Also, Mr. Hettinger should be proud of it because actually the graphics are his. But the pictures were taken by me. Major Shaw, do you remember where these were taken? Major Shaw is not going to report me to the mayor of the city of New York. These are pictures that I took at the largest field exercise that I think anybody has held. This was in November of 97 in New York City. The city of New York Mayor's Office of Emergency Preparedness decided to have an exercise where you had a simulated, actually this was a nerve agent exposure. At the top of the slide it says mustard attack. You'll see why. That's the scenario that I have on the next slide. But the actual one that they used was a nerve agent exposure. In fact, it was kind of funny. What they did was they had somebody dressed up as Mayor Giuliani giving an alleged political speech. You have a crowd of people who I think were high school volunteers. And you had three army, chemical and biological defense command people dressed up as terrorists, dressed up as New York City push cart vendors who sprayed the crowd with BX. And then the city of New York police and fire rescue first responder people came in. There's some of their vehicles and you can see the people in the level A suits picking up the casualties. Now this wasn't a perfect exercise by any means but it was the first one done to this extent. They had 200 vehicles. They had about 2,000 people involved I think. It was really quite massive. New York is probably as I will say several other times the most advanced city in the country in terms of being further ahead in their preparation. But look at the amount of money that was spent on this. I mean, the city of New York doesn't have all the money in the world and certainly most cities don't even have the amount of money New York has. So this is becoming a big thing in the civilian community. In fact, since you're all medical or medically related folks I will tell you they had 40 different hospitals in New York City that were playing into this scenario. However, none of those hospitals got more than 6 or 10 casualties during that exercise. There's only one hospital that's done an exercise with a lot more than that and that's Walter Reed and Dr. Natook is going to talk to you about that. Now the scenario on the next couple of slides is not mine. It was created by Jerome Hower who is the Mayor Giuliani's Office of Emergency Preparedness. And Jerome Hower put this together. I've modified it slightly but this is the sort of scenario that the civilian community is looking at. I'll read it through. The New York City police stage a raid on a suspected terrorist laboratory located on the lower west side of Manhattan and they are stupid enough to try doing this right at the beginning of rush hour on the weekday. And although the warehouse is empty when they arrive, it's booby trapped, explosives go off, the building collapses, it collapses onto a subway line running underneath which kills a certain number of people and releases a plume which is yellowish and the plume, most of the prevailing winds almost everywhere in the United States are from the west so this goes eastward, goes across Manhattan, northern Brooklyn into Queens. And in this scenario, within minutes people are observed coughing on the sidewalks within an hour you have people walking into hospitals in Manhattan and the other boroughs complaining of a variety of complaints, some of which are clearly hysteric, others of which may not be, all irritation, difficulty breathing and then later on you see people with blistering and skin erythema. And this is thought to be the way that say a mustard attack might look. At 0800, the Mayor of New York declares a state of emergency. I'll tell you something about states of emergency in the city of New York. New York is my hometown so I can say this. I remember when we had a subway strike several years ago and Mayor Koch was out spending most of the morning shaking hands with people walking across the Brooklyn Bridge, getting to work despite the fact that the subways were done. City of New York has a mayor who always will grant stand but that's going to be the case almost all the time. Where do you want your mayor? Well, the mayor here has to get the heck out of his office because his office is located in Lower Manhattan. Lower Manhattan is now being evacuated because it's not safe. Everything's in Lower Manhattan. The FBI office is in Lower Manhattan. Why is that important? Because they're the ones who have to deal with the crime scene, okay? The Emergency Operations Center, the fire department, the police department, all those have to be evacuated and reconstituted. And in Lower Manhattan is only one hospital but the other hospitals are now filled overflowing. Lower Manhattan is an unusual place. We have two and a half million people who work there and the vast majority of them do not drive. They take buses. They take taxis. Most of them take trains. How are you going to get word to these people not to go to Lower Manhattan? It's kind of hard. So tremendous logistical problems. And meanwhile, New York is also the capital of the world. We have the United Nations in town. And it's not inconceivable that the same day we could have a security council meeting plan where you have the Prime Minister of Great Britain, President of China, President of France, Prime Minister of Russia on their way to New York or in New York. New York happens to have more embassies than any city in the western hemisphere, more than Washington, because the United Nations is there. And these embassies start calling the president, saying, should we get our people out of New York? By the way, this could have been worse. It could have been Friday evening and Fourth of July weekend. Okay? This is just morning rush hour, just typical normal day. And here are some of the questions that come out the way this was proposed to us. In fact, major show it was Colonel Gerber, who is the facilitator for this discussion. So he can tell you more about it. You are, by dumb luck, one of the medical advisers to the city of New York. What do you do when the mayor says, Doc, I can't deal with this? Do we call Albany? Do we call Washington? Do we call the National Guard? Do we call the Air Guard? Do we call the mayor of Jersey City or Newark? Can he help me? Can I get people out? What do I need to know medically in order to get them out safely? When is it safe to go back in? How do I get the information out in a way that doesn't panic people? In the case of New York, I don't think there's any way you can do that, but there are ways that you can minimize that. And what do the hospital people know about this? How can I get the word out to them? Everybody in this room right now knows a great deal more about biological and chemical agents than 99% of the hospital people in the United States. I'll say that again. You are now more expert than 99% of the population in your fields. Now, you've heard that our intelligence estimate is that the threat is gradually increasing domestically, both Bio and Chem. And the reasons should be pretty obvious to you now. The FBI files, I said on the slide that they show a gradual increase in numbers of threats. Actually, the source of that statement is an FBI agent named Chris Breesie who invited me and some of the folks at RID to give briefings down at the FBI Academy. He's in charge of the Weapons of Mass Destruction Subcenter in FBI National Headquarters. Interestingly, most of the threats that they pursue at least this year are Bio rather than Chem. Luckily, as I think you've learned from Lieutenant Colonel Cislak, it's hard for the bad guys to get Bio right. And we haven't had much in the way of biological terrorism that's gone beyond the planning stage, the one big exception being which? The Rajneeshi attack with Salmonella on the salad bars in the Dolls, Oregon. But it's not clear that any others have been terribly successful. But the Bene Brith episode, which I think the folks at RID discussed with you at some length, it shows that the level of knowledge of these agents is relatively low and the panic that they cause can shut down the center of the capital of the United States with absolutely no agent, whatever. I'll show you one of Colonel Itzen's scenarios later on where you actually do have an agent. Now, this is something I went over before. I think in this class maybe, definitely in the other class, what are Chem and Bio agents good for? In the case of military situation, you can deny terrain, you can render a fighting force ineffective, you can kill people. But the terrorist doesn't have to do either of those things. All he has to do is to sow fear and panic. Both of these agents, Chem and Bio, are really good for that. They also paralyze your medical system. So you get a lot of what Prime Minister Thatcher of Great Britain used to call the oxygen of publicity. And how do you deliver them? This again you've already learned the various methods of delivery listed on the slide. I want you to pay particular attention to the one that says enclosed spaces. That's of particular relevance because especially with Bio agents, it's so unpredictable what your weather is going to be like and how far they're going to travel. An enclosed space is wonderful. And what's a great enclosed space? An enclosed space where people in large numbers are traveling through. So an airport terminal, a subway, a central station, Union Station, Washington, D.C. Or perhaps a place where people are coming and going all the time. The Pentagon. The New York Stock Exchange. And the one that nobody ever seems to mention, but I still have this thing in my ear about it, a tourist site, Opryland in Nashville. Some of the, an indoor ball game, an indoor sports stadium. Or some of the big country western places in Branson, Missouri. I guarantee you a town of 3,000 people is not equipped to handle this. Okay. So now I'm going to bore you to death, but I really feel I need to a little bit because this is like a language familiarization course. You are going to hear about the legislation that's come down and the programs for training that have come down in domestic terrorism. The president in the early part of the Clinton administration, I think it was 94 thereabouts, the presidential directive, establishing lead agencies for the federal component to any response. And it was basically just an assignment of tasks. One nice concept to remember if you ever read anything about this in the lay press is the distinction between crisis management and consequence management. I don't happen to like those terms, but we're stuck with them. Crisis management is defined as what happens before the bomb goes off. Consequence management is described as defined as what happens after. Lead agency for crisis management in the United States is the FBI. Basically, you're investigating a potential crime that's about to go on. Outside the United States, the lead agency is supposed to be the State Department, although I've noticed since I've started working with the State Department a little bit, the FBI always seems to be involved and the FBI believes that they have primary responsibility for an American installation overseas. Why is that important to you guys? Because you're military. So for example, when I flew over to Saudi Arabia two weeks after Khobar, the guy in the seat next to me was the FBI station chief in Detroit. And they were sending him over to do some investigation because they regarded that as an American federal installation on a foreign country. For counterespionage, I suppose, would be CIA, but that's not what the PDD says. Now, once the bomb's gone off, you have consequence management. The lead agency for consequence management is the Federal Emergency Management Agency, FEMA. Although what happens actually in the plan is that FEMA starts farming out responsibilities, and I'll have a slide about that later. But the training responsibility was given to the Department of Defense. Again, that may not seem all that obvious until you remember where you are. We in the Department of Defense really were the only people who were doing training on this at the time that President Clinton came out with this directive, and so the Department of Defense got the training budget and that turned out to be where all the money was. The next thing that happened, and this is something you will hear about, and on a lot of news coverage that I've seen, anybody ever heard of the Nun Luger Money, or the NLD, or the Nun Luger Amendment? Three senators, none of Georgia, who's no longer in the Senate, Luger of Indiana and Domenici of New Mexico, co-sponsored an appropriations amendment, which came out in 1996, and it is out there for five years, and who knows, it may be extended. And this established what we called the Nun Luger Program, which mandates that the Department of Defense as the lead agency for training establish a domestic preparedness program, and it set out the parameters of that program. That legislation mandates that the program have an awareness block where we familiarize people with the threat, that it have an operator block, which is where we train people who are going to be incident commanders. There's an incident commander block, there's a hazmat folks, incident commander is the person who's going to be running it, usually a fire chief, an EMT block for paramedics, and a hospital provider block, which was intended originally for emergency physicians and nurses. This, the responsibility for developing this program was given to DOD, DOD kicked it down to the Army, because the Army has almost all of the resources, and the Army kicked it down to the chemical and biological defense command. That's called CBDCOM, recently renamed. CBDCOM is headquartered about two blocks from here across the airfield. Most of the buildings you see around here are owned by CBDCOM. They also have a large presence at Fort Dietrich. They are what was the offensive program. We don't have an offensive program or chem or bio anymore, but they're the people who now mostly make their living developing countermeasures that are not medical. They develop most of the things that Mr. Hettinger lectured to you about. They are the people who develop level A suits and so forth. So they had this responsibility, several perambulations that's been farmed out further to a bunch of subcontractors, and we now have these four courses or five courses going around. The legislation stipulates, and this is a political decision, that it be taught at the level of cities. Not counties, not states, not federal. It was taught at the level of cities, and it stipulated in order to avoid offending anybody that the 120 largest cities in the United States would be the first ones to be trained, and they would all be trained within five years. Here is a list of the cities that have received this training already. This is fairly accurate. There have been a couple of changes to this list. San Jose got added, I know, and I think Baltimore hasn't had it yet, but this gives you a rough idea. They're roughly going down decreasing population size. And on the next list, you'll see the next group. There's going to be a break sometime this summer. A break and regroup. But this is an ongoing program, and you guys are paying this. The amount of money that this program costs is $50 million this fiscal year alone. Now, there are all sorts of political choices that were made. If you're training the 120 largest cities in the United States, you're automatically skewing it. For example, the state of Connecticut was left out. Why was Connecticut left out? Because in Connecticut, which is a New England state, the cities have not swallowed up their suburbs. The way Memphis and Jacksonville and Nashville have done so. So no city in Connecticut was big enough to make the list. Counties are not involved. In the case of New York and Boston, the city governments filled up the classes with people who were employed by the city. In Los Angeles, I think very sensibly, they said really the level of government we should be working with is Los Angeles County, because that's larger and we're really a metropolitan area, so they did get some people from the suburbs. Same thing happened in Washington, D.C., surprisingly enough. So there's a real political thing here. The Americans Association of Chiefs of Police has made a big point that we could do a better job than the Army. There's a lot of politics behind this. Another interesting thing that came out when Colonel Hurst and Colonel Eisen and I came to review the program, we said, well, gee, you're trying to reach, talking about the hospital folks, now we're trying to reach doctors and nurses. Where's your CME? What's that, they said, because they're not medical. And the institutes, RID and ourselves, we're not primarily in charge of this program at all, but as federal agencies that are charged with teaching this material to federal people like yourselves, we felt that we at least needed to make sure that what they were putting out was accurate. By the way, how long is the hospital provider course? It's eight hours. As two hours on nuclear, two hours on bio, two hours on chem, okay? So obviously it's a very broad brush program. We succeeded in getting CME for the program. In fact, it was Rosalie Holland who got it, because she has a nice tie-in with the AEMED Center in school, which is the accrediting agency that's giving you your CMEs for being here today, and we were able to do it faster than any of the universities. So guess what, I'm actually the CME director, because they needed to have a name. We're trying to get that transitioned over to a civilian agency, the organization we're trying to get to take over is the American College of Emergency Physicians. But to give you an idea, this is a very political process, and it's coming soon to a city near you. If it hasn't gotten there yet, there's no place in the country except Connecticut, Maine, where there isn't any city that's going to be trained. Now, there's another big issue that nobody has solved. What do we do after we train them? I'm in favor, this is, again, editorial. A lot of this talk is my personal opinion, having gone to a lot of these meetings. I think that what we should do is to follow the American Red Cross model and have some sort of certification, very much like BLS. Well, to get people to agree to that is very tough. I think the best organization to do it is probably going to be the ACEP, the American College of Emergency Physicians. From here on in, this is all concepts. How do you apply the basic principles of disaster management to the chem or bio context? Remember I said that crisis management is the agreed upon definition of what happens before the bomb goes off. Crisis is conceptually defined into two parts, planning and preparation. Really, they go on at the same time. And the major thing here is training, and the important actors are your police, your fire, hazmat teams. Let me tell you what it's like to train these people. The fire chiefs don't really have difficulty conceptually with this. They just have to learn the data. It's interesting, they're used to dealing with hazmat. They regard chem as essentially a special case of hazmat. In fact, many of them that I've talked to, the fire chiefs, feel that we are with chem agents about where we were with hazmat ten years ago. Bio is very different for them. It's a whole new world, and the whole concept of incident command that they're used to dealing with just doesn't quite apply. I remember I was at one meeting, and there wasn't anybody from RID at that meeting. I was sort of representing both institutes, and most of the people there were fire types, fire chiefs. And I was saying to them, well, you know what you really need? The concept that you have to have for a bio warfare terrorism incident is converting New York City with its 50 or 60 hospitals that tend not to talk to each other into Rochester, Minnesota, where the Mayo Clinic is, and everything's on one medical record, so that you could identify the epidemiology as fast as possible. That's not the way fire chiefs are used to thinking. So you have to sensitize them to that. Your health care professionals, not everybody in the country needs to take this course. Not everybody in this country needs to know how to treat plague. Once you know you have plague, you can just know where to turn. But we have to at least sensitize people to particularly the things that you don't have time to look up, and you guys know what those are. What are they? Probably nerve and cyanide are the biggies. And then to a lesser extent, some of the others. There are all sorts of problems with personnel protection, protection of health care facilities. Nobody has really dealt with this until very, very recently. And then you have to have a disaster plan. Now, every hospital in the country in order to be accredited has to run a mass cow. I would bet that 100% of the hospital-based people in this room have participated in mass cows. The best of my knowledge, Dr. Natook's mass cow is the first ever done for accreditation in Jaco in a chemical scenario. And I don't know of any that's been done in bio so far. How are we going to detect the agent? Remember that civilian community doesn't have the standoff stuff that we have here in the military. They don't have the protection, collective or individual. And they're not used to dealing with the public quite the way we are, although maybe we can learn something from them. And, you know, Ben-Abrith and Sarah are being good examples. So now the bomb has gone off. Now you've done all your training. Whatever training you've done, it's come as you are a war. It's just like Desert Storm. What happens? Well, there's always an incident command if it really is a bomb. That's true if it's a chemical agent exposure. Unity of command is something that most places are pretty used to, but there are turf wars. And this is a wonderful story that Major Shaw probably can attest to. At the New York meeting, I showed up and I knew that there was going to be a Marine Corps presence there. I'll tell you about the Marine Corps in a bit. I make funny jokes about the Marine Corps. Actually, the Marine Corps in some ways is absolutely out in front and doing a better job than anybody else. And this Marine Corps unit I'll tell you about in a second that always sends somebody along. So they have Major Mike Malone, Marine Corps Major. And Mike Malone shows up to every meeting impeccably dressed. He has his uniform pressed. Everything looks great. He looks exactly like a Marine Corps recruiting poster. So I made sure I had my class A's, and it'll look really good because I knew I was going to be there with Mike. And he shows up wearing a sweater and T-shirt, sweater and jeans and sneakers. And I said, Mike, what are you doing in the cities? He says, this is New York. I said, why? He says, let me tell you what happened the last time I came here. They were setting up this field exercise and they had Mayor Giuliani and they have all the major players there and I'm there as an advisor. And I say, Mr. Mayor, you need unity of command. And the fire chief says, I'm supposed to do it. The police chief says, I'm supposed to do it. This one says, I'm supposed to do it. And I say to the mayor, Mr. Mayor, sir, my best advice to you is you have to pick someone to be in command. So they come back to the next session. Mayor Giuliani leans over and points to the fire chief, fire commissioner of the city of New York and he says, you are in charge, Mr. Commissioner. Well, he says to me, ever since then I do not wear my Marine Corps uniform or any New York City policeman can find me. Okay? Police don't like me because they blame it all on me. But the fact is that probably Mayor Giuliani made exactly the right decision. At least he made a decision. At least you know who's going to be in command. Usually is the fire chief. Do you have a standoff capacity in the civilian community? No, you don't. So you're doing sentinel casualties. Our experience in Tokyo tells us that this may not work all that well. It took several hours before the Japanese doctors knew what they were dealing with. During that time, all of their hospitals had gotten contaminated. They made no attempt to decon on the outside. The physicians in Matsumoto a hundred miles away who had dealt with the same agent about six months before started making phone calls to Tokyo saying, we think we know what you're dealing with. The Tokyo doctors didn't listen to them for a while. So that's a communications glitch that we expect we're not going to do any better than the Japanese probably. How do you warn the population what's going on? What do you tell the media? What do you want the media to do for you? The media is not just your enemy. The media can really be your friend. You have to know how to use that. Now, the mayor may actually have a good staff to deal with his local media. In-place shelters. There's only one place that's really gotten into that other than Iraq, I suspect, and that's Israel. But we haven't really done much about that in the United States. Regulation, mass casualties. True story. Chobar Towers. Non-chemical, non-biological. This was an attack on American military base. Air Force is in charge. The Air Force is a military organization. Yes, it really is. They have, despite all the jokes, the Air Force in Saudi Arabia is very well organized. Despite all that, people are being picked up by ambulances taken to hospital A, hospital B. People were assumed to be dead and found to be in ICU beds two days later. That's in the military. Imagine what it's going to be like in New York City. And then the other problem that we've hit you over the head with over and over again, the walking worried, the psychogenic patient or the barely involved patient who, at least in Tokyo, those were the first in-patients to show up to the emergency room. Information dissemination. Do you want to be a journalist? No. But you have to know how to deal with the media. Media is not necessarily your friend, not necessarily your enemy and unity of command. That's really stuff that we've already discussed. EVAC. How are you going to evacuate lower Manhattan? I personally do not want the responsibility for that. I don't think any of us is going to have the direct responsibility for that, but we all may be in a situation where we have to advise medically those who are responsible for evacuation. By the way, in the military, anybody here connected with a unit, Army, Navy, Air Force, Marine, that infills the Korean theater, how many of you? Good number. You all have to worry about that because we have 130,000 civilians to get out of that theater when we start having bombs going back and forth and it's probably going to be a chemical theater. And do you want to evacuate people who may be in line for the next round? Then there's something called the recovery phase, which, again, there's a continuum. We in the military probably will not be directly as connected with this unless we are local. If this is Washington, D.C. is the target, obviously, those of us who work at Bethesda, Naval, and Walter Reed, Malcolm Grove will still be involved. But this is something that is of less medical importance. One of the major things that we may have to advise on is when is it safe to go in? And that's where the stuff that you've learned about biological and chemical agents in this course may come helpful. Issue that's come up, respiratory protection for people. There is one place in the world that's really gotten into this in a big way and that's Israel. Israel is the only country in the world where everybody has their own gas mask. Now, there are problems with gas masks, protective masks. Did Saddam Hussein cause any chemical casualties in Israel during the Gulf War? Well, everybody says no because there were no chemical rounds, but people died. Several people died because they had heart attacks while they were in their protective masks. At least two children were asphyxiated by their parents because their masks did not fit and they died. So did the Iraqis cause Israeli deaths in the Gulf War? They may well have. And believe me, the Israelis have not solved this problem. Although I'll be very interested in going over there in a couple of weeks. We have a financial conference with them and this is one of the issues that we're going to be discussing with them. Well, we have time to train everybody and as Colonel Natuck mentioned to it, who's going to pay for all this? Fire chiefs, when you go and talk to the fire folks and the municipal leaders around our country about this stuff, they get these great ideas about we're going to buy this, we're going to buy that. New York City has a Fox vehicle. They really do. You know, just buying the equipment is a major budgetary drain and just as Dr. Natuck said, it's a relatively low threat over a particular fiscal year. How can you justify the expense? The logistics. Hospital mask cows are one thing. Yeah. Is the military going to get involved in any of that? I've been decorated. Rigidly flexible. Are we going to get involved? Obviously, I'm involved now. This civilian emergency, not military related, would the military still be responsible for responding to this? Hold that thought. That's three slides down. Yes. The answer is yes. I'll give you an idea of how that works. But although we may have hospital mask cow, we don't really stress a metropolitan area yet in any of our plans and obviously that's going to take even more money. Are we going to preposition stuff? You know, all the antibiotics we've been hearing about, that all has a shelf life. Who's going to pay for prepositioning it? Who's going to pay for the vaccines? Are the vaccines even in existence? You remember what Colonel Hurst said yesterday? Botulinum toxin, we have 5,000 doses available at any given moment in the United States. Well, we may need to have a lot more than that if we think that that's available, that that's something we really need. And the other thing is ventilators. One of the things that we're probably going to have to do a lot more carefully is medical regulation of ventilator beds for all the reasons that you've heard this week. So now, Lieutenant Fasano, we start talking about how this is actually going to work. I got reinforcements coming to deal with you later. In fact, I sent him out. I sort of anticipated we might need to deal with you. Don't go anywhere. Traditionally, immediate response is going to be municipal. That's the way American government is set up. We have local control. The cities guard their prerogative zealously. It's probably going to be the local fire chief. And then you're going to have the police chief probably working for him. The EMS, all of us are going to fall in. All of us who work in a local locality, reservists and so on, we're going to fall in on the local fire chief and the emergency medical community. And that's going to be overwhelmed fairly fast. Doctrine states that at that point you go to the state government. Well, the state government may be helpful or the state government may not be helpful. If you are Billings, Montana, the state government may not have much to contribute. They may be too far away. They may not have much. One thing that the state governors have is a national guard. National guard can be very helpful if you happen to have the right unit. The problem is the national guard is spread out around the country according to where the army and the air force need those units and not because each state is supposed to be self-sufficient. So they may have a unit that's helpful or they may not. And then there's also this problem of city-state politics and this is exemplified. Major Shaw will attest that this actually happened in the New York pre-brief. Dr. Howard's assistant as mayor's office of emergency preparedness, we were working through that mustard scenario that I gave you at the beginning of the talk. And so he says, okay, I've got people dying in the streets. My hospitals are full. I'm going to call on the feds and I say no. What you really are supposed to do is to call Governor Pataki up in Albany. He has a New York national guard. He has various things. He has a state police. He has various agents. You're supposed to go through them. And he looked at me and he says, we'd much rather call the feds. We don't like to deal with Albany. There's a long history of that in New York City. New York City also has a lot of things that most state governments don't have. It has more money. It has its own medical examiner. So that may be an unusual situation. But the fact is that the state governor may not be able to help you. So at which point you call on the feds? Now how do you call on the feds? You call on the governor or maybe the mayor. Calls the president. The president declares an emergency. The FBI is mobilized almost immediately. The FBI regards this as a crime scene. I've given presentations on this stuff in front of FBI agents and I always have to tell them, don't get between me and my patient. Don't get between my nurse and her patient or my PA and her patient or my other physician and her patient. And I'm sort of beating them over the head on this because we don't want them to start dealing with it only as a crime scene. But when the government president declares an emergency, several things happen. The FBI is allowed to mobilize something called the domestic emergency support team, which is a, I guess it's a lynch mob size group of people. It fills up an airplane. It includes me. It includes somebody from RID, probably Colonel Christopher, possibly Commander Culpeper. It can include people from, it definitely includes people from FBI. It may include people from DOE, people from PHS, blah, blah, blah, blah, blah. A whole pile of people who go and assess the situation. And it can be tailored. But the RID agency for consequence management is supposed to be FEMA. And so FEMA opens up, they have this huge thing called the federal response plan. The federal response plan divides up into all sorts of different functional areas. ESF, emergency support functions. ESF-8 is medical. RID agency for medical is the Office of Emergency Preparedness of the Public Health Service, Department of Health and Human Services. They are mostly commission corps people. Person in charge of that is a Rear Admiral Knauss, Dr. Knauss, very nice guy. His operations officer is Commander Public Health Service, Kevin Tonat. Kevin is the person who's taught me all about this. And under them, they can pull in a very large variety of organizations, both civilian and military, all of which are in the federal response. But every time Kevin goes out and gives his presentations, he tries to impress some local communities, don't expect us in five minutes. They've done scenarios where they've responded to an emergency in Boise, Idaho. And it takes about a day to get all the feds in place in Boise. Because you don't have to just fly to Boise. You have to get them on the plane. And so it may take a while. The feds will come to the rescue and, of course, when we fall in, guys, this is important, we are not working for the President of the United States anymore. We are actually supporting the local community. So who are these military organizations? National Guard, we're not talking about here because National Guard has been used on the state level. We can be talking about active duty. Now, I'm an Army officer. The Army has by far the largest amount to bring to the table. In the case of the Army, this goes to Chief of Staff of the Army, kicks it down to the Office of the Surgeon General. There's also a Directorate, Two-Star General, Billet, Directorate of Military Support. It's commanded by General Soriano. But at our medical side, it goes through the Office of the Surgeon General, it goes through Major Shaw's boss, Colonel Fred Gerber. And he can pull almost anybody he wants from Army active units. He will pull us at ICD in the Institute of Infectious Disease. And he can mobilize the reserve, more about the reserve in a minute. The other side of the house there's a wonderful organization called the United States Marine Corps. The United States Marine Corps is an interesting organization. It's military... The way the military mission of the Marine Corps gets done is in a self-contained fashion. The Marine Corps goes out and they do everything themselves. They are very, very proud of the fact that they are self-sustaining. They are a short-term shock troop military force. And a few years ago, the commandant of the Marine Corps, General Crouac, realized that he had no internal, organic way of dealing with chem-bio-emergencies on the battlefield. He had to depend on the Navy because all of his medical was coming from the Navy. He had to depend on our expertise and so forth. And he said, we can't have this. The Marine Corps has to be able to stand alone. And so he created, under his guidance, an organization called the Chemical Biological Immediate Reaction Force, which is located at Camp Lejeune, North Carolina. It is commanded by Lieutenant Colonel Art Corbett, who is a Marine Corps infantry officer. He has, among his troops, 30 medical troops. The medical commander is a Navy Captain, 06. Captain Lori Belogurchik. She's not the only physician they have. They have a recon platoon. They have a decompatoon. They literally can do everything. Marine Corps really led on this. The people they have are superb. Sea Burf actually has its own, it must be the only military organization I've ever heard of, actually has its own board of directors and advisors, including one Nobel Prize winner, Dr. Joshua Letterberg. We are the advisors. In fact, Colonel Hurst and I are basically spelling each other at the next Reach Back meeting, which is next Monday and Tuesday. Yeah. Dr. Neymar, is this federal response, the same template that they use when active duty troops do disaster relief, for instance, when the 82nd... Very similar. Florida. Very, very similar. Yeah, because the Federal Emergency Response Plan covers everything. I'm talking only about ChemBio, but yes, this is a ChemBio application of the basic plan. But about Sea Burf, despite the fact that I give full credit to the Marine Corps for having done this, the fact is, I think that General Kroak almost did too good a job. He has created such a unique unit that it's probably never going to get used by the Marine Corps. When Sea Burf has deployed in the past, it's always been in support of a civilian emergency. They have deployed in support of the Atlanta Olympics, the Summit of the Eight in Denver, President Clinton's second inaugural in 1996 in Washington, 1997, actually. And so Sea Burf is a group that's going to get there too. They have their own airlift capacity. They won't be there in five minutes, and they can't sustain for terribly long, but Sea Burf is a major player. And then there's others. This is from an article, in fact all of these that I'm showing you are from an article that was written for U.S. News and World Report as a cover story. And what I really like about this is not just the level A suits, but the caption, because it says, even the Marine Corps has a chemical and biological response for us to deal with terrorist incidents. The fact is, thank goodness the Marine Corps has it, because nobody else does. Marine Corps has really pioneered a lot of this, and we're learning a great deal from them. Now, a comment about reservists. Sometimes we have more reservists in the class, and I didn't really know how many we were going to have. And the Air Force Reserve, to a lesser extent, plays a very interesting role here. First of all, the Army Reserve has almost all the civil affairs units we have. We have only one on active duty, and that's at Fort Bragg. So in the recovery phase, the Army Reserve may actually start being pulled in to assist in administration of areas that are being repopulated. It's part of the NDMS and the emergency medical system, because most of our reservists work in civilian hospitals that are part of the NDMS. But the reserve is now making, especially the Army Reserve and the National Guard Bureau, which covers both Army and Air Force, making a big play to take over perhaps part of the domestic preparedness program. Looking for new roles, I now understand that the regional medical commands on the reserve side, which are called RSCs, Regional Support Commands, the Army calls them, they want to have a response team comparable to the ones located at Army MedSense, of which Colonel Natoch is the commander of one. And then various backups for ChemBioResponse. For the next five minutes, I'm going to give you points that Colonel Eizen wanted me to give you. I am not a bio-expert, but Colonel Eizen is, and I have given him some points I wanted him to make, and he has given me some points that he wants me to make in front of you. So what you're now getting is the rid perspective of what Colonel Eizen considers to be important. Practically everything on this slide is stuff that you've seen before. It's been done before. It's going to be done again. Anthrax, Botte, and Reisen were in the Armamentarium of the Ome Shindikyo. We think in this country of them, in terms of Sarin, but they were very interested in Botte as well. And we have to be prepared to respond. Here's Larry Wayne Harris. Now, it's interesting. Larry Wayne Harris was in this course for years. Colonel Eizen always used to talk about Larry Wayne Harris, not because he had been under surveillance for years, trying to get hold of Anthrax in his house in Ohio. When we were in Fort Bragg about three weeks ago, Major Pavlin was with us, and she was really interested, because she'd been studying this guy for years, and here he was being arrested in Las Vegas. And here's the militia guys. These are people who attempted to kill a U.S. federal official with Reisen. The first people convicted under the Chembioterrorism Act of 1989 were trying to use Reisen, which is, of course, the classic assassination weapon. A lot of interest, but not that many actual incidents. Remember that the Ben A. Brith incident was a misspelled Anthrax, and it turned out not to have anything in it. Here is a scenario that Colonel Eizen put together for the Summit of the Eight. This is sort of the complement to the mustard attack on New York City. This is the Anthrax aerosol attack on Denver, Colorado. And if you read through this, they do it in a shopping mall. It could have been worse. It could have been Denver International Airport. But 90% of the exposed people were started on antibiotics by the end of day, too, but they can't find 10%. If it's the airport, imagine that that 10% might be 20, 30%. And if you look at this relatively small-scale bioterrorism, Colonel Eizen's numbers, as he crunched them out, indicate that even this small-scale event completely around Denver's resources. And, in fact, the 13,000 military medical beds deployed for the Gulf War would not have provided enough ICU beds. So this is his idea. And then this is his take on pretty much everything that I've already discussed, which made me feel good because when I put my slides together, I hadn't seen Colonel Eizen's slides, so we basically came up with the same points that we wanted to make. What we wanted to mention was the question of readiness, public health infrastructure. We have no good answers for this. Colonel Eizen has no good answers for this. And it's really sensitizing you to it. The last thing I'm going to do and I think that you can probably fill in these blanks for me, is to mention three or four issues having to do with chem casualty care, which might be different based on the civilian terrorist scenario versus the military scenario that really is where all the course that you've had up till now comes from. We were always preparing against a chemical attack. In order to get into a chemically contaminated environment on the civilian side, if you are a fireman, you have to be in an OSHA level A suit. That's the big blue suits that I just showed you. They're not allowed to use mop gear. We in the military can get away with mop gear, which is a lot cheaper. They're probably about the same. We're trying to get OSHA to modify it. Here's one of the chemical terrorists. I've forgotten his name. Oh, James Dalton Bell, chemist in Vancouver, Washington, who was building a little chemical lab in his backyard. I think he's the guest of the government now, but I don't know. Here's one that I'm really interested in. Anakin Vulsons for nerve agent exposure. Remember we taught you diazepam, diazepam, diazepam. Really, Valium. Diazepam, diazepam. Sorry, I'm allowed to say that. But in the civilian community, we do not use diazepam as an Anakin Vulson to all that much anymore. If we want to use a benzodiazepine Anakin Vulson, we tend to use low-raise apams. Diazepam is approved. We use it in the military for a lot of reasons, including the fact that it's stable and it's active I.M. But in the civilian community, they've gone beyond that. We've never gone through the hoops of the FDA to approve any of the other benzodiazepine Anakin Vulsons, and they do actually work as well. In fact, my days of lab works even better in laboratory studies. So for the domestic preparedness program, Colonel Hurston and I have taught the instructors to give out the following word. Everything in the course talks about diazepam, because that's the only thing that we're allowed to talk about. But we see no reason why in your emergency room you can't use low-raise apam to approve benzodiazepines. But that's a disconnect, and we haven't really solved it. A much bigger problem is mass decontamination. What are we going to do with the little old lady at the church supper who may have had exposure to aerosolized mustard? She needs to strip down to her birthday suit and allow the firemen to hose her down. And what happens if she refuses? She's not a member of the military. We can't force her to do anything. Are we going to have the fire brigade in the local community? And it probably is going to be the fire brigade. They're not used to doing that to people, okay? They're out there to save lives. They're used to people being grateful for their presence, not used to people screaming at them, do they have the right to force anybody to do anything? We have a bill of rights in this country. Surprise, surprise. And Battelle actually has a big contract with CBD com right next door to work on this problem. And they have not solved it. They're working quite hard on this. They've gotten a lot of emergency medicine, emergency fire, and police folks from the Baltimore-Washington area working on it. There are problems with having the stuff to decon. You can usually get water in this country. Tuna and wankits, they're not funded for that. They're not even funded for bleach, although it's relatively cheap. What are we going to do with people who are children, older adults, people who have respiratory diseases? And then the other issue that's come up and only George Washington University Hospital in the whole country has really faced is the issue of how you prepare or alter your civilian emergency room to do mass decontamination so you avoid the problem that the Japanese had of a good deal of contamination carried in on the patients into the hospital. And the last one is a biggie and that's children. All of our antidotes are presupposing an adult. In fact, they're presupposing a relatively young adult. All of you who deal with patients are well aware of the fact that older people are more sensitive to any medication. You also realize the children are small. Am I going to give an atropine injector to a four-year-old girl with a child but still respiratory compromised nerve agent exposure? Well in Israel, they have an answer. They want a dilados injector. This institute actually did develop such a thing but to field it is not something that the military will pay for. Who's going to pay for that? Is the city of New York going to pay for that? Is the city of Charleston, South Carolina going to pay for that or the city of the streets? You see, this is an issue that nobody really has solved completely and there are all sorts of other issues that you can think about for pediatrics. I wouldn't be surprised, although I'm not an expert in bio warfare, that some of our vaccines that we work on have not been tested in children. Children, my pediatrician colleagues tell me are not small adults. They're actually a different species. The last issue and so I was told when I was in medical school and the last issue has to do with triage. We treat we teach the principles of triage, of course you learned how we approach that in the military. In the military we're not happy about it but we've gotten used to doing the triage. But in the civilian community they may not be. Is a mayor going to be willing to accept responsibility for things that military commanders do routinely accept that responsibility for saying you're expectant. The mayor may very well say airlift into another city that hasn't been hit. So the whole question of triage, nobody's really dealt with this and I have no great answers. My job is to leave you with the issues that I think are important. So that concludes pretty much what I had to say. The last word I would leave with you is as you've heard, it isn't a matter of if we are told. It's a matter of when and how and how prepared we all are to face it.