 We're talking about Vesicans here this morning, and by the way, I'm a dermatologist. Vesicans are agents that blister the skin. That's just a fancy name for blistering agents. This is for a med center in school and to keep everything up and above board. You will know for these agents at the end, most of this, no one knows all of this because all the answers aren't in on all of this. I'd like to tell you right up front that you know how involved the treatment of nerve agents are and everything. I want you to relax because you already know almost everything about rendering the care to a mustard casualty because there is no magic bullet for mustard. It's all supportive. It's all the good medical practice that you already know, okay? So all you got to do is listen, learn the specific things here, and you already know how to take care of mustard casualties. Mustard, sulfur mustard is the biggie. I'm going to spend probably 90% of the time this morning talking sulfur mustard. And when I get done, you'll understand why and also why this old, old agent is still one of the top two concerns on the modern chemical battlefield. Nitrogen mustard, while very similar, has some significant differences that never has been, to my knowledge, really weaponized. Some of its forms are solid, some of its forms are explosive, some of its forms will eat through the shell. So it's never been really used, to my knowledge, as a chemical warfare agent. I would tell you, as a dermatologist, I have used it in modern days on patients as a topical medicine for a skiffin lymphoma called mycosis fungoides, and it's still used to this day. It was our first chemotherapeutic agent back in the 1930s, nitrogen mustard. Lewisite is very similar to mustard with some significant differences, and I'll teach you about those. The name Lewisite comes from Captain Lewis, a U.S. Captain Lewis who invented this stuff back in the World War I timeframe. It's my greatest aspiration to have a chemical warfare agent named after me. Just kidding. Phosgene oxene is made from Phosgene. We don't have another one with Phosgene in the name just to confuse you. I figured they did that when I took this course. But it's made from Phosgene, hence the name Phosgene oxene. And I'll spend just a little bit of time at the end telling you about that because it is important for one or two very specific reasons. So, for mustard, first synthesized back in 1822. And then we kind of forgot about it, and then it was rediscovered in the mid-1800s, way back in the 1800s. Its first battlefield use was in your pre-Belgium, 1917 July, right the last year of the war, okay? This is a breakdown of the casualties of World War I. There were roughly a million chemical casualties in World War I. 30% of all casualties in World War I were chemical casualties. But I'll show you this slide for a very specific reason. You've already been told that in World War I, less than 5% of the casualties were fatal, okay? And this is the breakdown. Now, if you look at the top three, they were under 5%. You look at the U.S., and we were at 2%. You look at Russia, they were almost 12%. We came into the war late. We had the benefit of lessons learned. We also had the benefit of some of our allies' equipment. Our first masks were not up to snuff. So we borrowed French masks initially, who had more experience because they'd been in it since 1914. So we were better prepared and better equipped because of lesson learned and because of better preparation and better equipment, our fatality rate was half of the rest of them. Russia, by comparison, you remember those masks that Dr. Seidel showed? They looked like something that your grade school would go in and cut out with cardboard. You remember those really funny looking, they're all funny looking, but the really goofy ones that the, that was their mask early on. The Russians had little or no protection at times. Their equipment was inferior. Their training was inferior and had a 12% mortality rate. I recently added this one in because I'm trying to make a point about education and training, what a difference it makes and preparation. These are the Kurds. Saddam Hussein gassed about 5,000 innocent people that were totally unprotected. And it wasn't a 100% mortality rate, but it was close to it. So what a difference protection, education and training make. Dr. Seidel deliberately preempted me with this slide yesterday, but a reminder that even though mustard came into the war, the last year of the entire war, it accounted for 70% of all the chemical casualties. And it's already been made, the point been made that the lethality is low. It's less than 5%, but it causes long convalescence. It really screws up the medical scenario. As a dermatologist, we very often look, but we don't see. How many will say you've looked right at something and was right there playing as a nose on your face and you didn't see it? In times past, I have been guilty of going around the house looking for my glasses and I had them on. I remember my grandfather, bless his soul, on occasion would go around the house looking for his pipe. And you know where his pipe was? He was making. So how many people have done things like that? I hope most of you. I hope I'm not unique, okay? And you know that most of these, I'll tell you and show you the percentages of the eye injuries, but you know, most of these were in the 75% category, had a mild injury that self healed in two weeks, but they were still taken out of action. They were a problem to the fighting effort, okay? You heard that even though there was no actual battlefield usage of chemical agents in World War II, there was the Barry Harbor accident. And I don't think I heard Dr. Seidel actually mention there were 600 US casualties and a little over 80 fatalities in that accident. We have no idea how many civilian casualties and fatalities. After World War I, you know, there have been chemical battlefield uses. We know the Italians used mustard against the Ethiopians. We think we're almost certain the Japanese used suicide against the Chinese leading up the World War II. We certainly know the Rockies used against the Iranians and the Kurds, and it's alleged that Egypt used it in Yemen. Now, mustard has lots of names and symbols. Most of them have H in it, okay? So anytime this course you see H, it stands for mustard, not Hearst, okay? I don't want anybody going around saying Hearstite or site or whatever. Here's one called HL and it's a mustard-luisite mixture. There's a very specific reason for that and I'm gonna tell you about that a little later. These, by the way, were called Levin's Tubes. They were like a poor man's mortar and it was one way they shut chemicals out of them in a World War I. You saw gas tanks yesterday. You see this structure, this is mustard. Most of these chemical agents have very simple structure. Some of them are as simple as water, like fozzy, you know, it's a very small molecule. And the only ones that are complicated, more so are the nerve agent ones. This substance down here is thiodiglycol. And you see the only difference is between thiodiglycol and mustard or the chlorines on the end. Well, thiodiglycol is one of the major urinary metabolites when it's gone through a person or an animal. It also is the number one precursor to making mustard in the most simple process of manufacturing and I know. If you have thiodiglycol, which, by the way, is a commercial product, use in making printer's ink and any number of things, all you gotta do is take thiodiglycol, throw HCl into it, hydrochloric acid, and voila, it makes sulfur mustard. A one-step process, if you have thiodiglycol and hydrochloric acid, you could make it in your bathtub if you were stupid enough. Well, there are people who are stupid enough. Take my word for it, not me, not me. Guess who was buying up all the thiodiglycol he could lay his hands on? Sodom. Guess where he was buying it from? One of the places. Guess where else he was buying it from? U.S. Now guess what the closest city was? One of the closest cities he was buying it from? Baltimore. Guess where there's some God people from that are serving time now? They were using intermediate areas. They weren't buying it directly, I don't think, but they still were breaking the law. Mustard is an oily, thick substance, and at times I have seen it in bulk containers. It looks just like dirty motor oil. It looks like my motor oil whenever I change it. Grungy, dirty motor oil. Heavier than air, heavier than water. Because it's oily, it has low volatility and it's quite persistent. Now here's a ringer. Look at the temperature. Depending on the manufacturing process, mustard freezes around 57, 58 degrees Fahrenheit. When I was in the Gulf War and the ground war kicked off, the temperatures were below that even in the daytime, so Saddam Hussein had thrown pure mustard at us. There'd been little ice cubes lying on the ground we could have laughed at. So this is a significant factor, but there are ways around that. There's more than one way around it, but I'm gonna tell you the biggest way around it shortly. The M8 test paper, okay, turns three colors. You can't read the writing, but the G agents turn kind of orangeish-yellow. H turns red and V agents turn a dark color, black, dark green, brown. You need to know that. The M9 tape is all or nothing. It turns red if it's exposed to nerve agents or Vescans. The M256 kit, which by the way is quite good. It detects vapors for these detect liquids. It's quite good, it takes about 20 minutes to go through it. It detects the Vescans, it detects cyanide, and it detects the nerve agents, the vapors. You need to know that. The cam down here is nerve agents and Vescans, mustard. It also will pick up lewisite, but it'll read it out as mustard, okay? Repeat that, I couldn't repeat that twice if I had. You know what? I'm gonna review you again and I'll repeat it. It's in your little handbook. You really want me to go through that again? Well, I asked for questions, didn't I? This is representative of the M9 paper and it turns three different colors, okay? And you need to go back and look in the little book. You should try and commit this to memory on the fly. The M8, yeah. It'll turn an orangish yellow or something for the G agents. It'll turn red for the Vescans and it turns a very dark color for the V agents. The M9 tape, you know, which is what people have on their arms and their legs, so you can, holy cow, it's turning colors. I better do something. It's all or nothing phenomenon. It turns red if you've been exposed to liquid. These are for liquids. The M256 kit is for vapors. It's a little kit. You're gonna fold this out and strike this and that. And you'll get to do this in the FTX. It takes about 20 minutes, but it detects Vescans, cyanide, and nerve agents, okay, vapors. The CAM, you'll see, you'll get a handle of this and look at it. You won't be made proficient with it in this course, but it detects nerve agents and Vescans. And remember, on the modern battlefield, the biggies, you're gonna hear about them the whole ball of wax in this course, but the biggies we're concerned about on the modern battlefield are nerve agents and Vescans and primarily sulfur mustard, okay? Mustard, when it gets on epithelial surfaces like the skin, it takes about two minutes for it to start doing its damage. So if you can decon it, if you know you've got it on you and you decon it within two minutes or less, you're gonna get off scot-free, okay? The problem with mustard is, it doesn't hurt you or anything. It could feel just like you got a little water on you or something, so it's a sneaky peat. It has a latent effect that I'm gonna tell you about. 80% of the liquid that gets on the skin evaporates. It goes into the air, it doesn't even damage. It's only the remaining 20% that does its harm. Now, they argue about how much does the local damage, but sometimes as little as 10% of that remaining 80% does the damage on the skin, the rest of it gets absorbed and goes systemic. You don't have to, this is what you need to know. You got two minutes to get it off of you before it starts harming you. The molecule I showed you of mustard is not the active molecule. When mustard comes into contact with water, it cycleizes into a closed little intermediary. That's the one that does the real damage. And it acts like grease lightning once it goes into that circular ion. Mustard, and I haven't said it yet, is an alkylating agent, just like nitrogen mustard, just like cytoxin, some of the other things. What alkylating agents do is they take carbon, carbon bonds, and rearrange them. So you can imagine that if the carbon, carbon bonds in your DNA have been rearranged, it's not too healthy. Likewise, it can affect the bonding and the carbon, carbon bonds in your cell proteins, your membranes. Mustard attacks just about everything it comes in contact with. But we know from studies that your cell proteins and especially the DNA in actively dividing cells are the most sensitive targets for mustard. And that tells us a lot about the mechanism of action of mustard. Thus, when your DNA in your cells has been rearranged on your epithelial surfaces, it can lead to cell death or mutation of the cells. Vapor, by and large, of mustard or liquid is an epithelial phenomenon. The number one sensitive area is the surface of the eye, the cornea, followed by the airways, the tracheal, the bronchial epithelium, and the skin. But if you look at these starting points, they're not that far apart, okay? But your eye is the most sensitive, followed by the airways and then the skin. Down here is what it takes to kill you. You learned about LD50s and CT50s yesterday, right? Everybody got that concept straight? Let me give you a hypothetical situation. I think you also learned yesterday that mustard is actually twice as toxic, twice as poisonous per weight as cyanide, which is a very dramatic agent because it acts so rapidly. If you took a meter cubed or if you took this room and you had a big enough puddle of mustard in here, liquid, and allowed it to equilibrate so that the room had vapor saturation, vapor saturation, depending on what studies you read, is around 600 milligrams. So you stick your head in a meter cubed closed area with enough liquid to come the equilibration saturate, and it only takes how long if that vapor has 600 milligrams in it for you to breathe in an LD50 unprotected by a mask. Takes less than three minutes for you to breathe in a poisonous, lethal amount of mustard in a totally saturated atmosphere if you have no protection. The skin, by comparison, if you were wearing a mask and you were totally naked and the vapor was hitting the skin, it takes 10,000 milligrams for a mustard vapor to kill you through the skin. These are all things so you know you have comparisons to trying and grasp somewhat intangible concepts. Liquid, by comparison, you've seen some pictures of mustard already and I'm gonna show you more, but to raise just an insignificant little blister like a poison ivy blister that, you know, similar, it only takes 10 micrograms of liquid mustard. Let me remind you that a microgram is a thousand of a milligram. Milligrams are pretty small to me already, but only 10,000 of a milligram of liquid mustard can at least raise a poison ivy-type blister on the skin. An LD50 of liquid mustard on the skin is around seven grams in your classic, swelled 70 kilogram male, you know, something like me. Well, he knows I'm lying. I want these cameras when you edit this, I want you to take 20 pounds off of me. You got that? Anyway, seven grams of mustard is a liquid LD50. Now a teaspoon is like five CCs. You know, a gram is equal roughly to a CC. So a teaspoon to a teaspoon and a half of mustard is an LD50, okay? As a dermatologist, I would tell you that if you had suntan lotion or oil and you took a teaspoon, a teaspoon and a half, you could cover one whole arm and your shoulder front and back and that's about 20% of your body surface area. So if a patient comes in with 50% liquid burns by mustard, 50%. How many LD50s have they gotten? You're right, you guys are sharp. Some classes you asked me, scratch your head and everything, it's 20 in the 50. I just told you 20%. They've gotten two and a half LD50s. How do you triage a person with 50% liquid mustard body burns? You got it. If somebody comes in with 90% of their body burns, and I'm gonna show you a picture of it, I hold your breath when I do later on. If somebody comes in with a darn near 90% body burns, how many LD50s have they almost gotten? They've gotten four and a half close to five LD50s. They're gonna be triage expectant likewise. Now I've told you that mustard's primary targets are epithelial cells and that's because those are rapidly dividing cells. They have the most sensitive DNA and it's eyes, airways and skin. But it does go systemic sometimes if you get enough of it. Well it goes systemic all the time, but it depends on how much have you got whether you have a systemic effect. But where do you have rapidly dividing cells internally? The bone marrow, the GI tract, CNS is not rapidly dividing, but we'll talk about CNS later on and of course in lymphoid tissue. But your systemic effects that you're gonna see most readily are gonna be bone marrow and GI if you get them. Hand blisters, this is a moderate to severe conjunctivitis with mustard. I'll show you larger pictures of this later on. These are bronchi. This is supposed to be smooth and round. You look in here, it's gunked up. You see the pseudo membranes. This is lung tissue that's messed up. This is a larynx tongue. I think you might have seen, I don't know if you've seen this one yet or not. But this is a crispy critter larynx. This is what a non-survivable dose of mustard in the pulmonary tract will do to you. It's just fried, okay? This probably doesn't show quite as well with the lighting, but this is the trachea and these are the bronchi. You see the ratty chunks here. You see, this should be smooth, contour, like a nice pipe. There's a big chunk here, how ratty it is. This is looking down on a bronchoscope. This is down the trachea and these are the two bronchi. Well, you can barely see in the opening. They're plugged up with the pseudo membranes. In World One, some soldiers died from the mechanical obstruction of the sloughing of the epithelium. That's what the pseudo membranes are. It's a physical, mechanical obstruction. You could take a bronchoscope in these days and go down and suck that out if you had those capabilities. This is another, you see how it's plugged up. I showed you that smaller before. Now, this is a slide I showed to make a point. Depending on what you read, the eyes, the lungs, and the skin, they all come in close, 85, 90, 75. It's all about the same to me. They all got affected in the burn when you got burned. So we expect the eyes, we expect the lungs, and the skin also comes in 75, 80%. But look what the top area was that got burned. And the men are already complaining up here. This goes to show men are dumber than, I mean, look down here, the hands and feet, you'd almost expect it to be reversed, wouldn't you? Why do you think this is? Were they all sitting around in puddles of mustard in their shorts or what? Collected in trenches. What kind of mop suits did they have in World One? None. None. They had uniforms. They had masks, but mostly they were just wearing uniforms in World War One. Now as a dermatologist, I would tell you that delicate, sensitive skin is most susceptible to medicines, drugs, or toxic agents. Warm, moist skin is most susceptible, more susceptible. And also, occluded skin, okay? So where do you have delicate skin that's occluded, warm, and moist? And then with vapor mustard going right through the uniforms and then kind of being held there, was a real setup for getting the growing burns, okay? I've told you, you got that it interacts in one to two minutes. You decon it in two minutes or less, you're gonna get off scot-free. They used to do this down in Alabama, Aniston at the Kim School, the non-medicals course in the old days when I would have been a young fellow. They used to put a drop, a mustard, a dilute drop on each forearm. They would allow them to decon one side in two minutes or less, and they didn't get a decon the other side. Guess which side always got the blister and a teensy little scar and which side never got anything? Well, the side you decon, clean his whistle, side I didn't decon got the blister. Mustard's onset of effects, you know, it's a latent period, it's been called radiomimetic. It's just like radiation effects, it's like some other chemotherapeutic agents. It's like ultraviolet light from the sun. You don't know, you don't feel anything, you don't know you're being harmed at first because of its delayed effects. So the onset is usually delayed from anywhere from two hours to two days. The average is about four to eight hours. Now, this probably isn't projecting well, but his chest is a little red. Mustard starts out and the erythema, the redness shows up first. Then it progresses to small little vesicles, which is a dermatologic term for small blisters, vesicles or small blisters. And if you got enough of them, they will go on to coalesce to form big blisters or bull eye, which is another dermatologic term for big blisters. There is the possibility with liquid mustard if you get a large amount on you and it doesn't get decon, you can skip all this. You can go straight to a third degree burn with a black eschar. It has happened, okay. This is the famous person you might have heard about yesterday who was working at a depot site. A little eyelet on the back of his boot let mustard drip in. And I think they say that they calculated that was about a 20 milligram dosage of mustard that made this blister. I have seen blisters that probably looked about like this or were caused by as little as the 10 microgram dosage. But again, two minutes to get it off of you. Two hours to two days to the onset. Obviously, if it takes two days for the symptoms to show up, you've got a pussy cat of an injury versus two hours. Two hours, you're in trouble, okay. Especially if it's a large area. Average four to eight hours. Just a blow up of a blistered hand with mustard that you've seen in the smaller picture earlier. Little bitty blisters all over. A couple big bull eye have formed from the coalescence. By the way, there is no mustard in these blisters. Hospital personnel medics are absolutely not gonna be harmed by the blister fluid. There is no mustard in these blisters. And this is an Iranian casually who has darn near 90, 95% mustard burns. You can see the giant bull eye, he is red, red red all over and he was a non-survivor. The eye injury, the mild conjunctivitis. There's an intermediate which is more severe, takes longer to heal with edema and even roughing of the cornea, swelling and a blephar spasm. And then there's a severe category that can be so bad there's even perforation of the globe and it could even qualify for legal blindness. The breakdown on this is 75% of them had the mild conjunctivitis two weeks and it could be back to duty. And they required little or no therapy. They just need a lot of TLC. The 15% intermediate took sometimes as long as two months, four to six weeks, more of a problem, but they would heal without residual. The remaining 10% were severe with residual damage and by today's standards about 0.1% of those patients would have met the criteria for legal blindness. And this is a blow up of the picture of a moderately severe mustard conjunctivitis, hemorrhage in the conjunctiva. This is a blow up of the burned up larynx tongue. The symptoms in the upper airway are gonna be hemorrhage, pain, hoarseness, strider, you can imagine. I mean, you're not gonna be feeling like singing any songs with a trachea or larynx that looks like that. Down lower you're gonna get bronchospasm caused by the inflammation, all the bronchi, and then the pseudo membranes will develop and can plug up the airways. With a massive, massive mustard exposure, you can get hemorrhagic pulmonary edema. Now pulmonary edema is not normally a feature of mustard. This is only with a very massive exposure. It is a feature of some of the other agents, but not mustard, only with a massive, massive exposure. There are three, when you die with all these agents, by and large, you die of pulmonary death. I mean, all of them, not just the Vescans, not just the pulmonary agents, nerve agents, all of them. It's essentially a pulmonary death. With mustard, there are three types of pulmonary deaths, okay? The first one, which is very much in the minority, okay? And with a massive exposure in the lungs. I liken it to it as if you had sucked on a blow torch or somebody poured lye or acid straight down in your lungs. The injury is so massive that you're just torn up down there, you couldn't possibly be a survivor and you'll die in one to two days. That is very rare, but it's one way you can die a pulmonary death with mustard. The most common way, and what happened to about 50% of the soldiers in World War I with the pulmonary injury, they got the lung injury, they got the inflamed bronchi, trachea, you know, pseudo membranes, and then along about three to seven days. Remember this, along about three to seven days, the secondary bacterial invaders came along and they got a secondary bacterial bronchonemonia. And guess what they, you know what they didn't have in World War I, they didn't have antibiotics. That's what took out about half of the soldiers with mustard in World War I. It was a secondary bacterial bronchonemonia that usually shows up three to seven days after the insult. The last way you die a pulmonary death with mustard is that at seven to 14 days, and the slide coming up will show you this, at seven to 14 days, if you've gotten a major systemic hit, the bottom falls out of your white count. And you get septic because you can't fight infection and you get sepsis and a secondary septic type pneumonia. And that's another way you can die a pulmonary death with mustard. And that's what I just said. Seven to 14 days, the white count drops. If it drops below 200 from experience in the Iran or Iraq war, you're very likely you're not gonna be a survivor. And then you get the secondary sepsis. In the GI tract, mustard has a cholinergic effect and is very poorly understood or not understood at all. And this is nothing like the cholinergic effect in nerve agent. But there are cholinergic symptoms, mild ones, early on within 24 hours with a significant mustard exposure that can give you bowel, cramping, diarrhea, nausea, vomiting, but that's transient. And it's not the same mechanism as nerve agent. Later on, if the bottom falls out of your white count and you get marrow suppression, but also if enough went into circulation and got to the GI tract, it can take out the GI mucosal, the epithelial surfaces. So you can start vomiting up, evacuating pieces of your GI tract, the epithelial surfaces, get a hemorrhagic diarrhea, and that's the effect, systemic effect on a GI tract. Now I don't want you to get the impression that this is like with nerve agent, that this is just a progression, like a massive nerve agent exposure. But there is a mustard effect in the CNS and it can be apathy and lethargy on the individual, or they actually can be giddy and euphoric. Why? It's not understood, but it does happen sometimes with a massive major mustard exposure. They can go straight to convulsions and die, okay? But this is not the progression like a nerve agent, and this is with a very large exposure, okay? And it's the minority, but it has been seen. I've told you that mustard has been called radiomimetic because it has a primary effect at the DNA, the DNA of your rapidly dividing epithelial cells, your bone marrow, your GI tract, okay? When the symptoms come on within four hours, you got a severe injury, okay? And it's really severe if it's covering, it involves your lungs or a large surface area on the body. If the airways, the symptoms are coming on within six hours, it's often fatal, okay? Now in the differential of these blistering agents, a couple of cases come in and they're not in any real distress. You still can think of insignificant things like poison ivy and poison oak. We had a case like this in the Gulf War, but it was a young trooper who was exploring the old Iran-Iraq bunker where mustard had been stored but had been taken out. He brushed up against the sides and he started with some burning and stinging about 12 hours out and within about 24 hours. So he had some little insignificant blisters about like what 10 micrograms would cause. And that was probably mustard. We couldn't prove it, we tried, but little isolated cases, no attack known or anything. You gotta think just the garden variety stuff. You start getting a number of cases in. If there's a lightened effect, it's mustard. If it's an immediate effect, it's lewisite or phosgene, oxyne. The lab, all your findings are nonspecific. You already know all this. You get an pneumonia, you get fever spikes. You're getting spikes for your WBCs, it can mean infection. Chest X-ray, if you got infiltrates starting to show up, it probably means pneumonia. You do as you would with a normal pneumonia. You look for a change in the sputum, you look for purulent sputum, and you do graham stains. If you get positive graham stains or cultures, then you initiate appropriate antibiotics. Prophylactic antibiotics only will select out a bad bug that will cause you more troubles. You gotta wait until the actor shows up and use the appropriate specific antibiotic. We did not have urinary thymodic glycol capabilities in country during the Gulf War. Anything we try to do had to be shipped back here. You now will have that capability in any future actions. There is a lab called the TAML, Theater Area Medical Lab, which will deploy to a situation like that. So you will have sophisticated laboratory capabilities available to you in theater in the next time this happens. As an aside, I would tell you that before Saddam signed his last agreement, this laboratory was getting ready to deploy. Anybody want to argue with me that an ounce of prevention's worth a pound of cure? I've convinced you, okay. With any of these agents, with all liquids, all liquids, your decontamination can get you off scot-free, and that can be just your little old 291 kit and get the spot off of you. Physical removal is everything in all this. I don't care whether you've got our 291 kit, you've got the Germans, diatomaceous for Earth, you've got the Brits Milton solution, the Canadians cream, I don't care what you've got. Physical removal is what really counts here because no matter what the active ingredient is in these things, they don't kill the agent as fast as I want it killed. The very best thing to decon with would be to jump in a shower and just shower yourself clean. Matter of fact, if I had that option, I'd get in it and they'd have to pull me out of it. So remember, it's physical removal. Don't get hung up on what you're using. Get it off of you by whatever means you got. That's sad, and we say this, late decon protects the medical personnel in the facility. That doesn't mean that a casualty couldn't have gotten agent off the mop suit that was lying here and needs some immediate decon. Or it doesn't mean that they didn't have such a large amount that some could still be lying there even though they got to you half an hour later. So when possible with these liquid agents, you always decontaminate at the earliest possible time. This is all common sense for all medical folk, okay? It's just supportive. Now down here, a raw denuded area always gets some kind of secondary mild superficial infection going on. That's why with these mustard things that are raw and denuded, you would use whatever topical antibiotics you have. You know, the surgeon, the sulfamylon, the vasotracein, neosporin, whatever you got. It's appropriate right off the bat. Systemic antibiotics, IV antibiotics are held in reserve. You can get a secondary cellulitis, you know, with the redness and the infection and stuff. You can get that, and you have to watch foreign culture and if you do get it, then you use appropriate IV antibiotics. Systemic analgesics. Anybody would argue that that one case probably needed a little morphine once in a while. You use whatever analgesics are appropriate. That could be as little as an aspirin or anihistamine all the way up to morphine. It is said, and I believe it from the literature I read, that a goodly portion of the soldiers in World War I died just from lack of modern-day IV fluids and electrolyte replacements. Mustard burns are said not to have the severe fluid requirements that a thermal burn does. Those of you who know, have treated these, had know that thermal burns take massive amount of fluids. Well, mustard burns require a lot of fluids, but they're not supposed to require the massive amounts of a thermal burn, but they do require good IV fluids and electrolyte replacement. I, again, is supportive. There's two things I want to point out here. With a mustard eye injury, you want to grease the rims of the eyelid, you know, with ophthalmologic ointment, antibiotic eye ointment, Vaseline if that's all you got, but you want to keep the rims lubricated. The reason being is that conjunctivitis is going to produce pus, polys. It'll probably be sterile pus, but if the eyelid is stuck together from the edema and the swelling and held together, and that pus doesn't drain out, a sterile abscess destroys tissue. You know, polys produce peroxide, so you want that lid to be open and draining, you know, so it doesn't get trapped behind you. This other point here, topical steroids in the eye, you know, this is a chemical type burn, and I've talked to lots of ophthalmologists, and every one of them have always told me they would use topical steroids in this injury. We do not have the laboratory data to prove whether this is beneficial or not, but I would like to be the call of the ophthalmologist. There are instances, obviously, if there's secondary infection, you don't want to be using a topical steroid alone. Also, if the injury is too severe, if the integrity of the globe is bleached, putting steroids in the eye and they go straight in can cause, you know, glaucoma problems, and so I would, by and large, right now, leave it up to the ophthalmologist, but it could be a very important part of their treatment. Sunglasses causes photophobia. It was the first use for photophobia or sunglasses and mustard in World War I. You can use topical anesthetics in a couple of situations. I could envision, and I sometimes address this as a pasted by, I can envision a casualty coming in, being semi-historical and a lot of pain, and you would need topical anesthetics just to get them under control so you could examine them. That's one appropriate use. Another one would be, as I said, so you or the ophthalmologist could examine them. Topical anesthetics, how many have ever had a corneal abrasion? It hurts, doesn't it? I had one and my friend ophthalmologist says, here, let me give you some codeine or percocet or whatever it was in those days, and me being a macho man, I am. I declined, I just took my patch and went on vacation, and I suffered the next two days like you wouldn't believe because it was so painful. But I did have topical anesthetics with me, like a wise doctor who shouldn't ever treat himself. You put the drops in for five minutes, goes numb, you feel wonderful. You probably could do yourself more damage while you don't feel anything. And guess what? In five minutes, it's right back. It doesn't, it doesn't work long enough to do squat. All everything we know, bronchodilators, the steroids here are for bronchospasm. They're not for anti-inflammatory. There's no indication that we have that it will knock out the inflammation. It's for bronchospasm. Atropine, this is not like a nerve agent. This is like a preoperative dosage, like for cramping and diarrhea, like 0.3 milligrams. That's what this would be for, for nausea, vomiting, diarrhea, if you have a cholinergic or GI effects of mustard. And we've talked the fluid and electrolyte replacement. You know, we're talking a lot of World War I data in Iran or Iraq war, because we personally haven't had mustard thrown at us on a modern day battlefield, and I'm very grateful. So we're talking about historical data, animal data, et cetera. I would bet you dollars to donuts that in a modern battlefield, if we weren't overwhelmed, it wasn't a true mass casualty scenario, and you can get people back to a tertiary medical facility, these people that would have died, I bet we can save a lot of them. It would save them with transfusions, okay? We get, there's male transplants that work nowadays. We may be able to do hormonal stimulation of the bone marrow, erythropoietin, anabolic steroids. Some of these things may work, and even just reverse isolation techniques to help with the bottom falling out of the bone marrow. Is mustard a carcinogen? You bet. You know, there's been a lot of talk about Gulf War illness and what does this and that. Mustard is absolutely a carcinogen and a mutagen. There is no evidence to date of reproductive toxicity in humans. There is some animal data of reproductive toxicity, and I know there was a show on television recently about the Kurds, which I didn't see and it suggested they may be bothered by 60 minutes, but I didn't get to see that. But I'm not gonna argue the issue one way or another. Chronic exposure, does it cause cancer? And chronic exposure, absolutely. There's good, clear data, and people who have been factory workers in the manufacture of mustard who got bronchial cancers, okay? Chronic bronchitis and emphysema, we don't know, and I'll tell you why, because the best work was done by the British after World War I, and they had about 12% or so of soldiers that ended up with chronic bronchitis and emphysema, but there were smokers, the air in England at that time was very polluted from burning coal with sulfur in it, and also these soldiers had also had a chronic lung bronchial infection that had to heal without antibiotics, so they had very scarred bronchi, okay? So they did end up with chronic bronchitis and emphysema, so you can't clearly say what caused what, but I won't bet against it. Acutely, one or two exposures, there's no evidence that mustard causes cancer. Chronic eye problems, absolutely, okay? You get eye damage and stuff, you get chronic eye problems. A very, you know, low percentage. Luocyte, Captain Lewis, World War I. That was Captain from the U.S., by the way. Has never been used, except possibly, by the Japanese against China leading up the World War II. No other known use, sparse data on it. It was very similar to mustard with some significant differences. Mustard freezes 57, 58. Luocyte freezes at zero. Guess what happens when you mix mustard and luocyte together? Drops the freezing point down around zero. Where were we gonna, where did we think World War III would be fought? Europe, where it would frequently be below its temperatures. Who had, has lots and lots of mustard-luocyte mixtures. You got it, the former Soviet Union, and they still got it. Heavy in air, heavy in water, it's oily, sometimes it's persistent. Said to smell like geranium. Now, mustard stinks. Mustard smells like garlic, onions, mustard, stinks. And you can smell it at very low levels if you have a good sense of smell. And luocyte said to smell like geraniums, so it's supposed to smell pleasantly. Is luocyte carcinogenic arsenic is in the molecule of luocyte. We don't know that luocyte is carcinogenic, but we know that arsenic is certainly a carcinogen. The exact mechanism of action of luocyte is unknown, but the primary, pulmonary lesion in luocyte is like that of mustard. It is necrosis to the bronchial epithelium, okay? But the exact mechanism is unknown. Eyes, airwaves, skin, just like mustard, it's primary epithelial targets. But look right here, here's a new one. Luocyte damages capillaries. I didn't say anything about capillaries with mustard. Luocyte damages capillaries and causes leakage. This is said to be a luocyte blister. That you need to remember, that is different from mustard. It damages capillaries, causes leakages, yes. I have a question. How would these be, would these be exploited and packed into munitions? Get him on the camera. Would they be sprayed and then just left in a local area? Say your question again. I said, sir, would these be packed? What kind of munitions would they be packed into? Would they be sprayed, or would they be put like in artillery shells? Yes, yes, I mean, yes. This class is starting to pick up. You guys are flat, you guys are flat, yes. This is what I like. You can deliver this stuff anyway. It can be sprayed. Most commonly, it is blown up, okay? It is either dropped out of airplanes in an explosive thing and you get an aerosol. The droplets that then can go on to vaporize, okay? That's pretty good. I like that. Luocyte causes immediate pain, okay? Mustard, you got the delayed effect. Immediate pain in five minutes, you're getting tissue necrosis, big difference, okay? Big difference. Blisters said to cause more necrosis and mustard, to the fact is we have very little experience with this because it's never been used on a modern battlefield. Very similar to mustard, okay? Except it's gonna be immediate. Same as for mustard. Aha. Remember I dwelled on the capillaries. One mechanism of action, the way Luocyte can take you out, is pulmonary edema and death. Your capillaries, you get damaged, you're getting fluids leaking into your alveoli, you get serious pulmonary edema, hemoconcentration, hypertension, and circulatory collapse and death. Just a progression, you know, the bottom falls out of your blood pressure, you're drowning in your own fluids, and it can take you out. Luocyte can do that in the lung. Aha. There is a specific antidote for Luocyte, unlike mustard, which is totally supportive. In World War I, they came up with British anti-Luocyte, Baal, or dimer caprol. Most of the time you think of, you know, British anti-Luocyte, Baal, B-A-L. Specific antidote against Luocyte. Remember I told you arsenic is in the molecule of Luocyte. Baal is a heavy metal chelator. It chelates up Luocyte and it does work. It's also used in other heavy metal poisonings, okay? It comes in all three forms, topical, ophthalmologic, and systemic. Don't even memorize this. If I ever have to use this, I'm gonna go to a little handbook and look up the mounts, but there are directions for using it. You ever heard that the treatment as bad as the cure? Well, there are side effects to Baal. They're not showstoppers, but it's kind of stuff if you didn't have to take it, you'd rather not. Phosgene oxyme. I thought when I took this course a hundred years ago, it wasn't bad enough. There were so many names and symbols, they had to go have one called Phosgene and one called Phosgene oxyme. Well, Phosgene oxyme is made from Phosgene. That's why you get the name. And CX, not CG. It is not a blistering agent. It is a very corrosive substance. It's said to be an erdicant. Erdicants cause a hive-like lesion before it goes ahead and rots your skin off. Very little amount about it. Here's why we stay concerned about it. They got it stockpiled, okay? The former Soviet Union. And they still got it. It's a very corrosive substance. While Phosgene is only a lung amp agent has no effects on the skin, Phosgene oxyme is a corrosive epithelial agent. But obviously, if you get this in the lungs, it also is a pulmonary agent. Management, there's no magic bullet. It's everything you know, just like mustard. Totally supportive. I would tell you though, that with any liquid agents, and we're talking about Vescans now, today, but with any liquid agents, what's the number one thing you do if you can? Decontamination, okay? Don't forget that, you'll see it again. This is a mini pickup truck from Saudi, okay? And those are camels, those are camels. And the question is, this is your test question, I promised you. How many camels can arrive in the back of a mini pickup truck? Two. One wrong answer, the answer was two. If you just kept going up, you'd eventually hit it, right? There's three, okay, three back there. One's facing out this way, one's facing right at me, and no one's facing out that way. And I never cease to be amazed in Saudi. This is not even a long bed mini, this is one little mini, and there's three big camels sitting in the back of that truck, happy as larks, and you saw it, I mean, you can ask anybody else there, if they saw this too. And I guess this just goes to show that camels are very right, a mile and a walk a mile. That's it. Questions? Sir, could you mention anything about the topical skin protectants that are being developed? Yes, I could. We have developed a topical skin protectant here. There's all kinds of side stories I can tell on this, but I'm already over and if you grab me at the break, I can give you a color commentary on these. But we have a skin protectant that's in advanced development and it's made from a commercial oil. We had to get the right texture and it's got these particles in it. They're actually Teflon particles and you gotta get the right mix and it protects. You can put it on your skin in closure areas and it will increase your protection on the bare skin to agents up to like four, five, six hours. And envision to be put in the closure areas, okay? Institute and currently we'll talk to this at the end of the course. We always bring them in because we'd like you to know we don't touch on all the neat things of stuff that's going on here for the future but there's lots of ideas for better protection down the line. We're also working on second generation on what is called a reactive topical skin protectant. Well, and we're trying a lot of different things but they took the regular topical skin protectant that's already in advanced development and one thing we did in World War II they were experimenting with all these topical protectants and I brought some 80 year old scientist up here who is a guy and invented this S-330 in World War II. He's still alive, PhD sharp as a tack. We took his old material S-330, put it in a new topical skin protectant and it doubled the time of the current one and it's reactive, destroyed. So they're working on, you know, that may not ever be the second generation but we got lots of good leads, okay? Yes. Do any of the agents or the other agents stay in the vesicles? No, not to my knowledge. Now the reason I made a point of bringing that out is there are crackpots around the world that publish all kinds of things and every few years somebody will come up with an article and say, aha, we found live mustard in a blister fluid that has been tested over and over again and it's not true, okay? And I'm not aware that any of the other ones would stick around. They react too fast. They're gonna damage tissue. I mean, it doesn't even make sense that they would still be there, okay? ["Live mustard in a blister fluid"]