Page 55 - JSOM Fall 2021

potential terrorists easy access to chemicals with devastating to encounter and can be equipped to respond appropriately.
effects. The ease of access to cyanide, chlorine, and other toxic As response systems vary widely in available resources and
industrial chemicals, potential difficulties in differentiating be- methods of response, it will be up to local and regional deci-
tween an accidental hazardous material (HAZMAT) incident sion-makers to use this information to create a local gap anal-
versus an intentional one, and delays in acquiring the appro- ysis of responder knowledge and resource allocation.
priate specialized personal protection and decontamination
equipment create a difficult response paradigm for medical Study Limitations
providers and emergency services. These impediments to effec- The GTD is a comprehensive record of global events. It is
tive, early intervention by emergency services are exacerbated maintained by START and is the basis for other terrorism-re-

by the low frequency of CWA-response training for specialist lated measures, such as the Global Terrorism Index. Reliance
providers, rather than training the general responders, who wholly on the GTD is partially mitigated by confirmation with
are likely to be first on the scene. 16,17 other lay sources and searches for other online searches, but
if there are incidents not reported in the GTD, this could limit
The medical response to CWA has also in many cases been the veracity of the findings. Furthermore, injuries and fatalities
deficient for a variety of reasons. For example, the Tokyo sarin were cross-matched with news records rather than formal hos-
subway attack saw great numbers of contaminated self-pre- pital or coroner reports, so this study relies on the complete-
sentations. This and the lack of early toxidrome identification ness and accuracy of these sources.
led to large numbers of hospital staff being poisoned. Rapid
18
diagnostic algorithms in toxidrome recognition, antidote use,
and clinical management of various CWA classes was until re- Conclusion
cently lacking, and there is likely a need for extensive refresher The use of CWA remains a concern given the rising rate of
training among frontline medical responders in this domain. 19 terrorist events. South Asia accounted for nearly 30% of doc-
umented historic terrorism-related CWAs, with the Taliban’s
The Tokyo sarin gas attack remains one of the most discussed operations in Afghanistan implicated in a large proportion of
terrorism-related chemical-attack events in the world. The events. Cult-related chemical events accounted for both the
20
use of VX gas, phosgene, sarin, and hydrogen cyanide by the highest death toll and highest NFI toll from an individual at-
Aum Shinrikyo cult in separate events is also documented in tack. First responders and healthcare workers should be aware
the grey literature, although the perpetrators never formally of potential chemical hazards that have been used regionally
claimed responsibility. 21 and globally and train to identify, treat, and respond appropri-
ately to CWAs using the multiple tools and algorithms devel-
Highly complex medical systems with emergency medical oped in recent years.
services (EMS) should be wary of these types of events: EMS
response could hamstring the local and regional medical re- References
sponse system due to symptomatic EMS personnel. The more 1. Organisation for the Prohibition of Chemical Weapons. Chemical
recent Syrian attacks using chlorine and sarin demonstrated Weapons Convention. 7 June 2020. https://www.opcw.org/chemical
the concerns when these events occur in a less-sophisticated -weapons-convention. Accessed 19 November 2020.
medical network already damaged by the ongoing civil war. 2. Publications UN. United Nations Treaty Collection. Treaty Ref
Guid. 2014;(July 1951):1–9. https://treaties.un.org/pages/View
The Syrian attacks showed what can occur with limited treat- Details.aspx?src=TREATY&mtdsg_no=XXVI-3&chapter=26.
ment ability, when the system was quickly overwhelmed and Accessed 19 November 2020.
antidotes were depleted early during the response. 18,22 3. Organisation for the Prohibition of Chemical Weapons. OPCW
by the Numbers. Published 2019. https://www.opcw.org/media
Identifying more effective medical response systems for CWAs -centre/opcw-numbers. Accessed 19 November 2020.
is critical, both to protect first responders and to save lives 4. Federal Bureau of Investigation. The Oklahoma City Bombing:
25 Years Later. 15 April 2020. https://www.fbi.gov/news/stories
from preventable deaths. The Paris Fire Brigade /25-years-after-oklahoma-city-bombing-041520. Accessed 19 No-
vember 2020.
has produced a chemical, biological, radiological, and nuclear 5. Farivar M. 2019 ‘deadliest’ year for domestic terrorism, says FBI
(CBRN)-focused tool based on the Chain of Survival initially director. Voice of America. https://www.voanews.com/usa/2019
used for cardiac arrest and subsequently adapted for high- -deadliest-year-domestic-terrorism-says-fbi-director. Accessed 19
November 2020.
threat, prehospital response by the Committee for Tactical 6. Tin D, Hart A, Ciottone GR. Hardening hospital defences as a
Emergency Casualty Care (C-TECC). 23,24 The tool emphasises counter-terrorism medicine measure. Am J Emerg Med. 2020 Oct
the use of spot decontamination initially, followed by early 30;S0735-6757(20)30947-5. Online ahead of print.
toxidrome recognition and early antidotes. After the initial 7. Court M, Edwards B, Issa F, Voskanyan A, Ciottone G.
stages of the CBRN chain, extensive decontamination is used Counter-terrorism medicine: creating a medical initiative man-
to protect the healthcare system and, finally, transport to a dated by escalating asymmetric attacks. Prehosp Disaster Med.
hospital. This tool is designed to simplify and order the most Dec;35(6):595–598. Epub 14 August 2020.
effective steps from patient contact through definitive care, to 8. Tin D, Hart A, Ciottone GR. Rethinking disaster vulnerabilities.
Am J Emerg Med. 2020 Nov 6;S0735-6757(20)30973-6.
reduce the complexity of response, and to reduce morbidity 9. Human Rights Watch. Memorandum to Convention on Conven-
and mortality in CWA attacks. 25 tional Weapons Delegates. The human suffering caused by in-
cendiary munitions. Memo to Conventional Weapons Delegates.
This epidemiological analysis of CWAs over the past 50 years 2011;(March):9-10. Accessed December 9, 2020. http://www
can be used by responding agencies to determine their educa- .hrw.org/en/news/2010/11/22/memorandum-ccw-delegates.
tional and operational needs for future CWA response. By un- 10. Walsh D. More than 200 Ugandan sect members die in church
fire. The Irish Times. 20 March 2000. https://www.irishtimes
derstanding the types of weapons used, individual responders .com/news/more-than-200-ugandan-sect-members-die-in-church
can be taught to recognize the toxidromes they are most likely -fire-1.257587. Accessed 20 November 2020.

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