Antidotes for Everyone

For five seasons of Fox's hit television show 24, lead character Jack Bauer and his colleagues at the Counter Terrorist Unit have struggled to protect the United States from threats ranging from bioterrorism to nuclear attack. This makes for great entertainment, but it also reflects real threats we face in the world today.

Chemical Concerns
      The plotline for the 2006 season of 24 focused largely on a terrorist threat involving a chemical nerve agent. While not considered as high-impact as a nuclear device or biological agent, a chemical nerve agent is a much more probable weapon of choice for terrorists in the real world.

     Unlike nuclear and biological weapons, chemical nerve agents are relatively easy and inexpensive to produce and deploy. These poisons, which include organophosphorous insecticides such as malathion, parathion and diazinon, are readily available in our communities and travel via road and rail through our cities every day.

     Chemical nerve agents have already been used in terrorist attacks. In 1995, members of the Japanese cult Aum Shinrikyo released the nerve agent sarin into a Tokyo subway, killing 12 and injuring 5,500. The year before, members of the same cult released sarin into an apartment building in Matsumoto, killing seven and injuring more than 200.

     A 2004 Homeland Security Council report outlined a terrorist attack scenario in which a chemical nerve agent released in three large office buildings could kill 95% of the occupants, the equivalent of nearly 6,000 people. The report estimated that first responders would arrive on scene in 10-15 minutes-a response likely to be too little, too late, given the rapidity of nerve agent poisoning symptom onset and the logistical challenges of providing immediate medical assistance to large numbers of victims.

     In the event of a chemical nerve agent attack in an enclosed area (e.g., a public transit system, indoor stadium or office building), individuals who have been poisoned may have only minutes to receive an antidote. Emergency responders in the U.S. have access to auto-injectors that contain the antidotes for chemical nerve agent poisoning. The problem is that in many cities, responders may have only enough antidotes to treat themselves and will not be able to obtain more to treat victims in time.

     The Hurricane Katrina disaster underscored that local emergency responders must be prepared to manage a disaster for 24-72 hours before federal assistance arrives. Unfortunately, most state and local emergency management agencies do not have standardized protocols to guide their responses to a chemical nerve agent attack. Most are depending on federal government stockpiles of antidotes, but those caches will not be immediately available and may not be delivered for 12 or more hours. And most do not contain adequate supplies of infant and pediatric dosages.

Layers of Support
      Even before the tragedy of 9/11/01, New York City implemented a layered inventory and response system. Every ambulance in the city carries a stock of chemical nerve agent antidote kits as standard equipment. Victims who are most severely affected by a nerve agent would receive their initial antidote treatments from the first ambulances on scene. Logistical Support Units represent the next layer of logistical support, followed by pre-positioned caches of antidotes. These local layers of reinforcement would be utilized before federal assets, such as chem-packs supplied by the CDC, are required.

     State and local emergency response agencies have the opportunity to acquire chemical nerve agent antidote kits through grants from the federal Office for Domestic Preparedness, at no cost to them. It is important for agency leaders to partner with other state and local officials to assess their risk for a chemical nerve agent emergency and develop standard response protocols similar to those of New York City. During an emergency is not the time to realize you don't have a plan. And Hollywood heroes like Jack Bauer won't be there to protect you.

     For more information on first responder grants, visit the Department of Homeland Security at www.dhs.gov.

Jerome Hauer is the former director of the New York City Office of Emergency Management and former assistant secretary for the Department of Health and Human Services' Office of Public Health Emergency Preparedness. He was also the state EMS director for Indiana and deputy director of emergency management for NYC*EMS.