 They're basically two kinds of chemical agents. What are they? Incapacitating the other one is toxic. What's an incapacitating agent? Incapacitating the agent is something that doesn't kill you. Let me give you my take on incapacitating agents, and I apologize to those who've heard it before. The mental image is of the British troops charging the German trenches in World War I. There have been a few wars since World War I, but we haven't had a real big chemical war since World War I. And as you've noticed, this whole post, except for its interest in nerve agents to a large extent, is still refighting World War I, so I'm always talking about World War I. So the British are charging the German trenches led by the regimental bagpiper. Why are they led by the regimental bagpiper? Canary. Canary? Well, that's actually a reasonable thing. However, the bagpiper is inhaling the air that he's carrying in his bagpipes, and so, you know, it works as a rather poor gas mask. Is he there for aesthetic effect? No. Is he there for moral support, unless you're Scottish? Probably not. Most British troops are not Scottish. They're English, or at that time Irish. The reason he is reading the charge is that they are fighting the Germans. The Germans are the most musical nation on earth, a nation that produced bombs, Beethoven, Bach, etc. And the British know that once the Germans, the great music lovers that they are, will hear the bagpipes. They will have to cover their ears, and in order to do so, they will have to drop their weapons. And therefore, they will be incapacitated, and the British can carry the positions. So that's the picture of an incapacitating agent. And there are two kinds we're going to talk to you about. One is the riot control agents, and the other is BZ, which Colonel Mass will talk to you about. And the whole point about an incapacitating agent is it doesn't cause any long-lasting effects. It simply allows you to take somebody down. And so, of course, these were invented originally by law enforcement. And the riot control agents are a class that were originally invented by the Parisian police in the very early days of this century to deal with all of the demonstrations. The Socialist Party under Jean Gervais had massive street demonstrations, and they were invented by the Parisian police. And so, for historical reasons, we classify them as the first chemical agents used in World War I, because the Parisian police were conscripted into the war effort very early. You have the pictures of the Parisian taxis carrying people off to the front lines. These are some of the synonyms. Now, how many people here remember the 1960s? Oh, come now. How many people here were tear-gassed in the 1960s? Oh, gosh. Saw it on TV. All right. Been there, done that. Saw the t-shirt. Okay, tear-gassed is a misnomer for precisely the same reason that Dr. Seidel told you yesterday that nerve gas is a misnomer. These are not gases, but that's what everybody tends to call them. And there are some other synonyms. You'll see up there there's this wonderful word. When I came to the institute, which is not very long ago, I had to learn a whole new vocabulary so I can now share it with you. Have you ever heard of the word sternutator? Okay, does anybody know what it means? New word for the day. I knew we would have the opportunity for true education. A sternutator is something that makes you sneeze. However, riot control agents are more of value to law enforcement, not because they cause people to sneeze, but because they cause you to tear and they're highly irritating to exposed mucus membranes. And you already know what's the most exposed and potentially harmed mucus membrane in the body. The eyes. Okay, so that's what's called tear gas. Now, what are the riot control agents? They are a series of relatively complicated chemical compounds. They're not chemically related to each other. That's an impression you would get by looking at the NATO codes because they all begin with C or D. But they're actually all different. CA and CR are old pre-World War II agents. Nobody stockpiles them. Nobody has them anymore. They don't really enter into this at all. CS, how many people here have been exposed to CS? Should be almost everybody. CS, I wrote it down because I can't remember the name. CS is orthochlorobenzilidine meleno-night trial. And nobody expects you to remember that because I didn't even put it on the slides because it's not terribly important. Although it is nice to remember that CS, because its name ends with nitrile, it has a CN moiety in it. It has a cyanide moiety in it. And CS is, as you all have experienced, as I have experienced, the agent that the military uses in gas chambers for training purposes, not just in this country but in a lot of others. CN, which as Colonel Madsen already mentioned, and I want to get this right, is one chloroacetofinone, therefore a chlorinated compound, is also called MACE. Anybody ever used it? MACE used to be marketed to the civilian community. You could go out and buy it. It's basically being phased out. And those are the two that have been used for a long, long time by law enforcement in this country. The other completely unrelated compound that fits into this category, we won't say too much about it, is something called atomzite, which has the NATO code DM. Atomsite, Colonel Hearst likes to say that there are ways in which you can become immortal. George Bernard Shaw, anybody know his play, The Devil's Disciple? There's a wonderful line in there that is attributed to the character, who I think really is George Bernard Shaw himself, but it's actually General Burgoyne, saying martyrdom is the only way by which you can become famous without regard to ability. Well, atomzite is an example of how you can become famous by having a horrible agent named after you. It is the vomiting agent. And then, for completeness, we classify within this category of agents, pepper spray, which you probably have had some contact with. These are the first agents that we've discussed in this course, which are honest to goodness solids. So they're doubly incorrect to call gases. They're actually solids. But they really are as powders. Now, how do you disperse a solid? You have to put some sort of energy behind it, because a solid likes to sit there. Now, where have you in this course dealt with agents like that? You dealt with it up at Fort Dietrich, because essentially an anthrax spore is a solid, too. So is an organism for our purposes here. It's not going to just disperse easily the way a gas or a vapor is going to disperse. The reason that the right control agents that we're talking about in this hour are of value for law enforcement is that it takes very little to disable you, but it takes a heck of a lot to kill you. Why is it that law enforcement wants you to stay alive? Well, yeah, actually the real reason is the lawyers. I hope we don't have any jagged folks here. The real reason you want the high effective ratio is that you want to take somebody down without causing them any long-term damage. And that's why law enforcement latched onto these as far back as 1910. And they are very rapid-acting and they don't last very long, just like this lecture. That's how I remember it. That's why I get this moment. We were used by the French in World War I militarily highly ineffective and have not really had a lot of military uses since then. They were used in the Russian Civil War. We in the American military, the one major use that we have had for these was attempting to disable people when we were charging into tunnels in South Vietnam. After the war we realized that probably wasn't very effective. The North Vietnamese really were not slowed down by this very much, and there were lots of tunnels that we had never discovered, which we thought we had. But the law enforcement community, of course, uses these a lot, and there have been some rather controversial uses of this, not just in the 60s. The odor of the 1960s being the tear gas in places like the Chicago Democratic Convention 68. But much more recently in the Branch Davidian Siege in Texas, the idea of law enforcement was to get the people to surrender peaceably, and they attempted to do this by pretreating the compound with a lot of CS agent. The problem was that it didn't work, and they then went in and an explosion ensued. Now CS, especially in a confined space, is quite flammable. That's not something we usually like to use it for. But you can make the argument, and I really don't know how strong it is, but it's certainly possible to argue that the law enforcement pretreatment of that compound with CS agent made the explosion worse than it might have been or made the fire worse than it might have been. A lot of uses in refugee camps in the Middle East in various times. The major time that we run into these agents in the military is in training situations. Remember, I think it was this class, and it may have been the previous class that I mentioned. There is one live agent chamber for nerve agent, and that's down at Fort McClendon, Alabama. Other than that, CS is the agent that you have been exposed to for military careers, is used for crowd control, and as mentioned, especially for people who don't want to carry firearms, there's a big paranoia industry, and they manufacture these and market them to the civilian community buying for self-protection. In fact, some of you may have carried them in your handbags or in your glove compartments or wherever. Now, these things, as mentioned, are all, with the exception of CA, a rather obsolete agent, solids at room temperature and normal pressure. And they have extremely low volatilities. They don't sublime. You know what sublimation is? Sublimation is what you see with carbon dioxide. If I have a crystal of carbon dioxide solid, it will vaporize directly from solid. That doesn't happen here. It doesn't happen with ice either. So while you just think of it the way most of the solids that you're familiar with, I don't see any clouds wafting up from the plastic at the formica coverings of the tables here. And the same thing is true here. I've got to give this stuff some juice in order to disperse it. And that's why you have these aerosol cans. The idea is that you have some sort of explosive potential. And you can disperse it in all sorts of ways. The pen gun is the one that probably the CIA likes. But you can have any kind of grenade bomb. It doesn't really make much difference. And unlike chlorine, some of these things are relatively stable and they may actually survive that. Now here's a bunch of numbers, none of which are important. I think the only thing that's important on this slide is to look at the difference between the numbers on the left, which is how much of this stuff it takes to get in effect. And the effect I think in most of the studies has been tearing of the eyes or I feel it, or this is uncomfortable. This can be done in humans. Versus the amount it takes to kill you and I think that was not done in humans. And take a look, for example, for CS, the range is from 10 meg minutes per meters cubed to 61,000, or roughly 6,100 times as much is needed to kill you as to have an effect. For cyanide, for example, that might be a close to a one-to-one ratio, or two or three-to-one ratio. Here we're talking about a 6,100-to-one ratio. And it's these ratios that recommend them to law enforcement. And what do they do? They imitate mucus membranes. What mucus membranes does a wafting powder cloud have access to? Unless you've got a sitting open wound, it's basically going to be eyes, nose, and to a lesser extent the upper airway. And so you see burning, tearing, injection. And what actually causes the law enforcement value of this is that people have so much irritation that they shut their eyes real tight. And so they really can't amount effective resistance and you take them down. And then the same thing basically happens in the nose and the mouth. You have burning, sneezing. So how many people have actually experienced these symptoms yourselves from these agents? Didn't quite get the mass confess. Okay, and I hope you all agree that that's really what you experienced. In the airways, you can get burning, tightness of the chest. These are, what, central or peripheral effects? They're central or even higher than that. I mean, this is like an extraordinarily mild version of some of the things that Colonel Baxter discussed to you with you in the pulmonary electric. And then, especially if you're sensitive and we never know who is, if you have enough of the stuff on, you can get a little bit of skin irritation, but that's relatively less common. Now, DM or Adamzeit is sort of like the other RAG control agents, but with the trimmings. The trimmings are GI. I hope there's no gastroenterologist here because they probably don't want to be considered that way. But basically what happens is you get everything plus your barf. So it's tear gas plus barf. It takes a little bit longer to have that effect on you and lasts a bit longer, doesn't affect the skin. Why in the world would anybody develop such an agent? And that's why we talk about it in this course. Do you have any idea what's the value of that? Exactly. You can't keep your mask on. And that was the idea. The idea was that you challenged somebody with a combination of DM plus one of the other agents. It turned out not to be very workable. And I don't believe any of the militaries around the world now is still involved in using DM, but this is why it was developed. Now, there are some potential complications. They're all relatively rare. In fact, they're extremely rare. You can get a delayed dermatitis, very rare. You can get a real problem with foreign bodies in the eye, but pretty much you have to have the stuff sprayed really at close range. And you can have exacerbation of chronic disease in the airways. Now, as Colonel Baxter mentioned, roughly one-sixth of the population is reactive airway disease. Not only that, but if I'm using this on a crowd of people, say in Times Square in New York City, a certain percentage of that group of people is going to be, say, over the age of 65. A certain percentage of that group of people is going to have chronic obstructive pulmonary disease. They may be smokers. They may have had a bunch of pneumonia. And this is, again, one of the reasons why law enforcement agencies are a little cherry about using this stuff, because they don't want to be sued for making people worse. And some lawyer will pull out the medical literature and find that these riot control agents can, in fact, make these pre-existing symptoms worse. So you don't want to use these things indiscriminately. This is a picture of a very severe exposure to, I think, CN. By the way, remember, what is CN not but sound like? Cyanide. Cyanide. NATO code CN is estophanone and not CN-ion. What does this look like? If I had never told you anything about riot control agents, riot control agents, yeah, exactly. It looks exactly like a mustard casualty. I can't tell the difference. But the amount of riot control agent it takes to give you this is many orders of magnitude higher than the amount of mustard it takes to give you this, as I hope you recognize from Colonel Hearst's talk. And we can go all the way through this. I think that we'll skip asbestos for this, because basically riot control agents are not something you're going to have difficulty making a differential on. How do we protect ourselves? Same as with anybody else. Of course, the problem with riot control agents is that being predominantly used in non-military populations, people don't usually walk around anywhere except maybe Israel with gas masks doing about their day-to-day tasks. And you can decontaminate, which is really what you need to do, or treat the lesion. Actually, what do you do for most people? Has anybody here who works in an emergency room treated a patient who walked in saying, I was tear-gassed by the police? Several of you. What do you do for them? Wash their face. You wash their face and scent them on their way. And especially if it's a light exposure, you may not even have to wash their face although we recommend that you do it, because it's a solid. You can just brush it off, and it's going to go away and it'll sit down on the ground and it's not going to vaporize and cause problems later. Fresh air, soap and water. Maybe dilute bicarbonate, maybe. We do not recommend bleach. And the reason is that bleach does actually react with CN and CS and can damage the skin. So easy. Soap and water, which is usually all you ever need. Occasionally, the dermatologists tell us you have to worry about the equivalent of a first-degree burn. I don't know how often, but certainly less than 1% of the time. Topical antibiotics, only if my dermatologist tells me to use it. And the real problem is going to be in the eyes. And you're talking about mucous membrane exposure. Bronchodilators, oxygen-assisted ventilation. This is basically for any exacerbation of reactive airway disease. Anything that causes reactive airway disease. It's kind of like the weather department warnings. People with pulmonary disease should not go out today because there's a lot of particulates in the air. And for the eyes, get rid of particles, foreign body sensation, foreign bodies, topical antibiotics. This is just good emergency room nursing physicians care. Nothing terribly upsetting. What happens if you end up eating this stuff, if you're an animal or if you're a child? Not a totally crazy question. You're going to get a bad gastritis. Surprise, surprise. Plus all the other things in the GI tract, by the way, if it happened to be Adam's eye, but you're not going to see that. There is no Adam's eye out there in the civilian community. But you're probably not going to have any real chance of dying, luckily. Again, this stuff is relatively safe. CS, as I mentioned, is a Moenonitrile. Small theoretical possibility you could liberate cyanide from it. We know that you have an increase in thiocyanate, which you have just learned is the metabolic product of rodentase, our own wonderful enzyme that detoxifies cyanide. So we know that if you're exposed to CS, you are going to have a slight increase in your cyanide concentration. Remember, you do have a normal cyanide concentration. If you're a smoker, you have more than most people. After aerosol, however, it's just not been seen, and that's very reassuring. This is, remember, oral and IV, I can get cyanide, and that's probably done in people in a small, small exposure. But in a confined space, there have been a small number of patients, maybe two or three in the United States who have died from exposure to CN. And this is the real reason why these agents are being phased out, especially for people just buying at Kmart. They do not want to buy anything that could potentially be held later in a court of law to have caused death. And of course, eyes, if you have something right up against you, you're going to have serious problems, but it's not because of these agents. It's because of the force of the aerosol or whatever system that delivered it to you. We will get in the terrorism lecture to think a little bit more about the fright, fear, sympathetic nervous system response. Maybe much more of an issue when you're dealing with a crowd that's had this stuff delivered to it by the forces of law and order. And pretty much all of these things are back to baseline, but this is your flight fright escape response. This is just the big animal is bearing down on you in the prehistoric jungle. Now, what's replaced these agents for civilian Kmart thing? It's pepper spray. And what is pepper spray? Actually, what pepper spray is, not very different from what the waitress gives you when she says to you in the restaurant, would you like some fresh ground pepper on your salad tonight, ma'am? It's really not very different. It is just ground extract of capsaicin containing peppers. Capsaicin is the active ingredient. Capsaicin lives in, as you see on the picture, little glands at the bases of certain members of the pepper family. And capsaicin is also used in medicine. Does anybody know where? Capsaicin cream? Capsaicin cream, exactly. I'm a neurologist. Capsaicin, because of tolerance, can actually decrease pathological pain syndromes. It's used in post-herpetic neuralgia, for example. It's manufactured under the name Zostrix. Okay, so you may have run into it again. In case you've seen it, I wanted you to realize that you've seen this before. The idea is that between CNCS on one hand and capsaicin, the comparison is that capsaicin is supposed to be better on animals, which is actually very helpful if you're dealing with a rabid animal. It is helpful, supposedly, more helpful than CNCS on people under the influence of alcohol, lasts a shorter period of time, and generally has much fewer the side effects that I've already mentioned. Now, remember I said there are all sorts of ways you can become famous. There's a man named Scoville who decided to become famous in an utterly unique fashion. Scoville decided that he was going to measure how hot things were, and he invented something called Scoville Heat Unit by which he has become immortalized. How in the world do you think he did this? I used to think when I first came here, what? He asked people. He asked people. Yeah, it really is that simple. I used to think it was some of these high-tech things. No, no, no, nothing at all. He got a bunch of grad students or normal people. I think it was about 12 people, and he had all these diluted solutions of peppers, and he just passed them down the table and said, can you taste this? Can you taste this? Can you taste this? And worked out this scale, which he then published, and nobody else bothered to repeat it, so we still use his scale. Does anybody know what the hottest pepper in existence is? The Habanero, exactly, which has a Scoville Heat Unit scale of about 6,000. Green Bell Pepper, said to say, is zero. Pepper spray, about a million. And Pure Cap says, in about 15 million. So it's really a matter of how long you purify it. So now you know all about Scoville Heat Units. You never expected to learn when you came all the way to Aberdeen. And this is really, all you need to know about rat control agents, it's not a lot. They were used in World War I, but really are not very effective military agents. They are not recognized by the United States as official chemical agents, as mentioned. Now let me show you, this is my little demonstration thing. About two months ago, here at the institute, we were picking up on the web an emergency room nurse, and I do not remember where she was not military, she was civilian, had an inquiry about a product she had heard about. And so I got hold of this and I wrote the company, which is in Michigan, and they sent us these free samples. This is something called BioShield. This is not an endorsement at all. But this comes with a video, and this is being manufactured for law enforcement agencies, police departments. And I'm showing you this, mostly to give you a sense of the regulatory and malpractice pressures that are driving police departments. Dr. Fasano, could you hold up your... This is our perpetrator. Could you hold up? Perpetrator who's been doing nasty things and we have just exposed this perpetrator to riot control agent, and he is not very happy. He has blepharospasm. He can't see, so when I handcuffed him, he didn't notice. So now he's fine, but he's not very happy. And now being a nice, warm-hearted police officer that I used to be before I was wised up, I want to make sure that he is safe and sound before I put him away for the night. And what I'm supposed to do is I'm supposed to take this bio-shield stuff and spray him, and he immediately stops. It's...that's what the... And if that doesn't work, I have this little bio-shield teller. So we were really interested to see what the heck is this stuff. And so we got the fine print, and the fine print says, active ingredient, non-toxic herbal extracts. So basically, they're taking these plant oils, and it very well may be, nothing more or less than snake oil. We haven't analyzed it. We really don't care. But the point is, this is a company that is making money on the fears of police departments that they are going to get sued for the use of these things. That's all I have to say about it. There's very little to know for exam purposes. The major reason that these are included in the course is A, differential diagnosis, and B, historical.