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University at Albany Center for Public Health Preparedness

CHEMICAL RISKS IN YOUR NEIGHBORHOOD

Original Satellite Broadcast: 05/04/04

MODERATOR: Hello, and welcome to this morning's program, Chemical Risks in your Neighborhood, the final program in this season's broadcast series presented by the University at Albany's Center for Public Health Preparedness. I'm Peter Slocum, and I'll be your moderator today. Before we begin, I'd like to ask all of you to please take a moment after the program to fill out your evaluations, either on-line or on the forms, which your site coordinator has provided. Your feedback is crucial to the development and future funding of our broadcast programs. I'd also like to let you know that we'll be taking your questions later in the hour. The toll-free number is 800-452-0662. We can also take your questions by fax at 518-426-0696. To address the topic of chemical risk in your neighborhood, we have today guest speaker Dr. John Urbanetti (phonetic sp.), who fills a number of important roles, including Director of Chemical Casualty Consultants, Consultant to the U.S. Army Medical Research Institute for Chemical Defense, and Clinical Assistant Professor of Medicine and Pulmonary Diseases at Yale University. Thank you for joining us today, Dr. Urbanetti.

URBANETTI, J.: Thank you, Peter.

MODERATOR: Could you please tell us a little about your work as we begin our discussion?

URBANETTI, J.: Well, I'm a lung doc at heart with intensive care training, and I practice half time doing that. Interested in this subject largely because most problems that we have with chemicals in terms of healthcare are inhalational problems. The other half of my time I spend with various government departments, particularly state department now, traveling around working with state department embassy level issues of coordinating for large scale events.

MODERATOR: Alright. Well, if we pull back to the small scale a little bit to begin our discussion to build on that. Let's talk a little bit about our neighborhoods and what chemicals we should be concerned about that we're potentially exposed to.

URBANETTI, J.: Well, there are a variety of chemicals that are found in the homes. And we have a list of that set of chemicals presented here right now. Chemicals that are very, very toxic in terms of the damage that they can create. We don't see an awful lot of lethal effects of these chemicals largely because the amounts are so small so that exposures are very important, awareness of how to deal with the exposures is important, but concern in terms of major scale healthcare comes from large stockpiles of this type of material.

MODERATOR: And we do have those stockpiles in our communities. It's not something far away across the continent. It's right in many cities.

URBANETTI, J.: Exactly correct. Chemicals are an inherent and important part of our life. Consequently, stockpiles of those chemicals for industrial use and for other purposes happen throughout the country. And those stockpiles are important and part because they're there and accidents happen and part because materials get transported and accidents may happen in that regard, too. So that your second list of chemicals here are pretty much the same kinds of chemicals that we find in the home, but they are chemicals that are now, because of large amounts, a very important issue as well.

We'll talk about each of these chemicals separately a little late on in the program in order to identify the specific dangers and particular risks of those.

MODERATOR: Okay. Well, historically when many of us think about chemicals agents used as weapons, and of course that's I think what's at the top of most people's minds. We think about World War II and mustard gas and so forth. Can you tell us a little bit about what really happened during World War I? I think I said World War II. I meant to say World War I. And what the effect of those chemicals as warfare agents was.

URBANETTI, J.: In World War I and in fact in most wars around about that time and subsequently, damage that occurred because of what we call conventional weapons, bullets, bombs, shells, would be damage that had a death rate of about 30 percent for people. About the time of World War I, military planners looked to other methods of doing damage, if you will, and the use of chemicals as a weapon became a tool. The tool did not create the death rate that we talked about. The death rate with chemicals in World War I and subsequently is about three, four, five percent. Much lower than the death rate with conventional weapons. And so one might say, "Well, why would the military personnel think that chemicals would be useful?" The utility of chemicals was the low death rate producing injured people who would then be unable to fight but who had also to be taken care of, so that you'd get two or three for one. Injury from chemicals rather than death from chemicals. Chemicals are looked at as very dangerous things. But in terms of comparison to other weapons, in fact, they're much dangerous.

MODERATOR: Now I noticed on the slide that we had up a minute ago, there was a real outlier, and that was in Russia. The death rate there was much, much higher.

URBANETTI, J.: Well, you look at the death rate here for Russian troops, 12 percent. Four times the death rate for instance, American troops in World War I. And that was largely because Russian troops were young, sometimes 12, and 14 years old. They were sent out without equipment and without training. And that makes a very critical point that simple training, planning, and equipment reduces risk of chemicals massively.

MODERATOR: Right. So the Army and the military planners around the world did prepare to respond to those kinds of threats. And we have sort of primitive masks were the first response I gather. Were they effective?

URBANETTI, J.: The first chemicals used during World War I were chemicals that did damage by breathing them in, chlorine for instance. And so the defense, clearly, was to put some kind of device between you and the outside world. A mask, a gas mask. Many different things were tried for gas masks. You see for instance the middle picture here, a piece of cloth simply used draped over the face, and that had some effect. It wasn't perfect. Gas masks were developed in World War I, found to be necessary in fact for animals as well. You saw the horse wearing a gas mask in that kind of picture.

MODERATOR: Uh-huh (affirmative).

URBANETTI, J.: Gas masks were very effective as long as you use them.

MODERATOR: Right. Hence, the importance of training.

URBANETTI, J.: Training, equipment, fitting, and we all know about this because we do this now regularly in hospital settings. Fit masks for various reasons. World War I was such an important learning point in terms of chemicals and breathing in chemicals and how to defend against it. And also recognizing that World War I chemical use was so effective, if training wasn't in place, that chemicals were developed and used, planned for use by most countries. As World War II came down the pike, we all knew that chemicals were going to be used. And we were afraid that the civilian population would be exposed to chemicals as well. So we planned and trained for civilians to have protection of some sort.

MODERATOR: Hence, this sort of anomalous slide we have coming up I think next of Mickey Mouse.

URBANETTI, J.: Well, that's the Mickey slide. This is one of my favorite slides ever. World War II, Walt Disney was hired on by the government to try to find ways to make it possible for youngsters to wear a mask and not be afraid. And so the Mickey Mouse mask came out.

MODERATOR: I see. It was not used I think.

URBANETTI, J.: Not used. Thank goodness.

MODERATOR: And in fact, very little in chemical weaponry was used during World War II aside from the horrible tragedy of course of the gas chambers that we'll talk about later. But in actual battlefield usage, there wasn't much of it.

URBANETTI, J.: Exactly correct. The anticipation of use of chemicals was high. Everyone was afraid that chemicals might be used. They were not used in World War II. But after World War II, a large number of plans were developed by many countries to manufacture and use chemicals. And we see the gulf area here to make the point that chemicals were used on a number of occasions, particularly in the gulf right up to and including the Iran/Iraq conflict.

MODERATOR: Right.

URBANETTI, J.: Using chemicals that are World War I type chemicals.

MODERATOR: Now what happened to the stockpiles that were prepared for use in World War II that were never used?

URBANETTI, J.: Well, the United States had very large quantities of chemicals both in weapons and in standard storage mode, developed for World War I, developed for the Cold War. Those stockpiles have been located in now eight places in the United States. Chemical stockpiles maintained, monitored by, guarded by the U.S. military with destruction plans clearly in place to clean up those chemicals. Very elegant and very well-defined destruction plans.

MODERATOR: And when we were chatting before, you said that probably the communities which are most prepared for any kind of chemical accidents are those which are around those stockpile sites in the United States.

URBANETTI, J.: Peter, that's an incredibly important concept to keep in mind. We're going to talk more about large-scale events. And we're going to say, I hope clearly, that the biggest problem in any large-scale event is not lack of equipment or lack of staff or even staff training so much as it is logistics; getting things organized and getting them onto site in preparation. Around each of those stockpiles in the United States, all of the chemical training that has gone on has been directed toward medical, fire, and police support teams so that they learn how to respond. That makes those communities by far the best prepared communities in this country for any large-scale event.

MODERATOR: Switching from the military environment and the stockpile to the civilian one, there are a tremendous number of chemicals, as we said before, in industrial settings. Does the average person have much of an idea how much a quantity of chemicals is out there?

URBANETTI, J.: I think the short answer is no. I think that the amount, number, quantity of chemicals stored, transported through, and potentially effecting communities, not well recognized. And we're going to say that in a couple of ways today. That there are large amounts in tank cars, large amounts in storage facilities, which unfortunately are not protected facilities. We are smart enough to know how to take care of these from a safety perspective. But accident or intentional problems are steering us in the face.

MODERATOR: And the safety measure that you would ideally like to see, that experienced people would like to see, are not really in place to the extend they should be.

URBANETTI, J.: Well, I would turn that around a little bit, Peter, and say that our record of accidental events in this country is extraordinarily good. We have good protection, good planning, and good storage. Way better than most other countries.

MODERATOR: Uh-huh (affirmative).

URBANETTI, J.: It's the intentional release of some of these things that could be accomplished very easily and presents us with the greatest risk, I believe.

MODERATOR: And of course the terrible incident in Bhopal India a number of years ago reminded everybody around the world that the degree of risk and the potential for intentional release as I understand it.

URBANETTI, J.: Well, the Bhopal event was a signature event in understanding large-scale chemical events. 1984 a U.S. corporate structure, which was manufacturing chemicals in India, manufacturing them there for sale in the United States. Manufacturing them there because we have low-cost labor, a), and regulatory structure was very different. They had an event, and the event was an event in which 50-thousand gallon tank of a particular chemical let loose and immediately affected 150 thousand people. An extraordinary number of people right there right now. A small percentage died.

MODERATOR: I noticed on the slide earlier that three percent.

URBANETTI, J.: The original slide said death rate was very much similar to what we saw in World War I. But in one fell swoop, there was a number of deaths and a number of injured similar to what we saw throughout the entirety of World War I. This is a single 50-thousand gallon tank. The event was an event that to best information today was not an accident. It was not an accident. And it is important to keep in mind that 50 thousand gallons is the standard tank size for chemical storage facilities, number one, and number two, needs to be compared to the 30 to 33-thousand gallon tank size that's on every railroad car transporting chemicals, that is on the back of every tank truck transporting the same identical chemicals through your community on your railroads.

MODERATOR: Right. So that potential clearly is there.

URBANETTI, J.: You bet.

MODERATOR: And the disaster, which we have avoided that disaster so far in this country, but it's not beyond the realm of possibility.

URBANETTI, J.: We've avoided the intentional release I this country. We've had some accidental releases of tank car equivalents, of chlorine and other substances that teach us how important it is to be able to respond quickly. I mean, we have a slide here I think of the ramifications of the Bhopal event, which show us that there were a large number of people who died, somewhere between three and 15 thousand. You see the number 38 hundred, but entire families died. And so there was no one there to say, "Where's Aunt Minnie?"

MODERATOR: Right. I see.

URBANETTI, J.: The death numbers here were tough to come up with. Number of people disabled subsequently, 11 thousand. That's a conservative number. The number of people who will go on to have long-term effects, very important up to and including death. A huge number of dollars went into trying to support the structure in India and much work is still being done today.

MODERATOR: Right. Are there any other recent large-scale events that focus our attention on these kinds of issues? Chemical?

URBANETTI, J.: We kept seeing the large-scale event as a risk is conceptually important, because it teaches us how likely something is, but even more importantly how well we'll respond to it. And the Tokyo subway event with nerve gas --

MODERATOR: Right.

URBANETTI, J.: Not a correct word, because nerve agents are actually liquids. But with the nerve gas event, is important from an understanding and management point of view. So we'll talk a little bit about that I think most usefully. The event happened in 1995. It happened in fact nine months after a practice by the same terrorist team.

MODERATOR: Right.

URBANETTI, J.: And most terrorist teams actually have practice events, and then they have the real event. And when the real event came down the pike in 1995, release of nerve agent in the subway in Tokyo, individuals exposed recognized that something was happening, and they rushed to the nearby medical facilities. They didn't stand around waiting for somebody to come and pick them up and take them there.

MODERATOR: Right.

URBANETTI, J.: Injured individuals get up and if they can, go directly to hospitals. The important first point, because that means that hospitals are really first responders here.

MODERATOR: Right. They're going to see those people.

URBANETTI, J.: They're going to see them right away.

MODERATOR: Right.

URBANETTI, J.: They'll seem them right away. And we have some very good information from the nearest large-scale what's called a level-one hospital in Tokyo, St. Luke's.

MODERATOR: St. Luke's. Right.

URBANETTI, J.: And there's some data here on the first slide about the St. Luke's hospital experience. Within -- In fact, the first day, in fact the first hour, nearly 600 people appears at their emergency room. By the end of the first day, 640 people. That was an equivalent emergency room experience to what they see in two weeks.

MODERATOR: Oh, I see. So totally overwhelmed that capacity.

URBANETTI, J.: So it's a huge number of people. Totally overwhelmed the capacity. Ambulances brought those people in, some of them, a very small number, much later than the first people themselves arrived on foot, by car, commandeered bicycles, etc., etc. So that -- huge influx of people. The people who first get to an emergency room are who? The well ones; the people who are well enough to get there. And if emergency rooms don't understand that very well, they will take in all of the well people, fill up their system, and then be unable to manage the more sick or even severely sick as they start coming in perhaps 45 minutes later to an hour later.

MODERATOR: Right.

URBANETTI, J.: So that is a very important learning point.

MODERATOR: The triage capacity, the flexibility is extraordinary.

URBANETTI, J.: That's the right word. That's triage. That's triage. What we'll do is show you, to make that point clearly, a little video clip. Real life, real time video clip from St. Luke's hospital. We'll see a picture of their emergency room area.

MODERATOR: Okay.

URBANETTI, J.: Outside first then inside. We'll see the picture actually 45 minutes after patients have started coming. So it'll first be one of their emergency transport facilities.

MODERATOR: Okay.

URBANETTI, J.: That's a piece of tape. Department of Justice presents this to us. Here's an ambulance arriving at the emergency room. And what you see in this emergency room are people without protection. No one here is wearing personal protective equipment, PPE. And they're handling the patients directly. You see what I hope for you looks like confusion, because there is no one in charge except for that fellow in the blue suit who is bald. I always say bald people are in charge. People are not organized and not structured. That fellow in the blue suit here actually is the CEO of the hospital who ought to be managing rather than out there with hands-on activity.

MODERATOR: With the people out of the ambulance. Right.

URBANETTI, J.: And it's just the wrong kind of structure. Next we see the inside of the hospital. And inside the hospital nurses, doctors, handling patients one at a time. Patients have not been cleaned. The nurses themselves and doctors are not protected. They're doing what they're trained to do. In Japan, their large-scale events are mostly earthquakes, and so everyone gets an intravenous. But that's not useful in this particular disease. You see off in the distance here a room that looks a little bit blue to you with a cross on the wall.

MODERATOR: Right.

URBANETTI, J.: When there are large numbers of patients brought into this hospital, if there are too many, they put them into that extra room.

MODERATOR: The chapel.

URBANETTI, J.: That's the chapel. That's their surge room. And the room was prepared for that. They have ventilators. They have I.V. hanging devices. They have oxygen supply. But they didn't have ventilation enough. So as they pack the room full of patients who had gas on their clothing, the materials came off their clothing and affected nursing staff and physician staff. But you see the confusion here. There's no organization. No structure. That led to perhaps two or three extra deaths because of poor training and planning. Not because of lack of equipment, not because of lack of personnel.

MODERATOR: And while they're trained for earthquake disasters, had not trained for this type of event.

URBANETTI, J.: Large-scale chemical events were not part of their training program. The slide that will be next available to you here shows you some of the longer-term effects from the event. There were 12 deaths. Actually, I'm fond of saying there were 12 and a half deaths, because there was a person who arrived at the emergency room with no pulse, no blood pressure, no spontaneous breathing. Walked out of the hospital three days later making a very important point that this is a totally recoverable illness, providing people are trained adequately and ready to go with the illness.

They looked at from the hospital a number of these people who came in the first day. Six months later, striking piece of information. Most of those patients, over 50 percent to 60 percent of those people six months later had persistent and severe psychological symptoms sufficient so that they weren't back at work.

MODERATOR: Right.

URBANETTI, J.: Big issue in terms of the expense of taking care of these people.

MODERATOR: We've seen that in some of our earlier speakers in this series talk about the psychological impact on a community and saw exactly that sort of -- Different numbers, but the same.

URBANETTI, J.: A critical point. And some people who reflect on this say that the dollar cost of taking care of the emergency medical issues on the same first two or three days is about equal to the dollar cost of the long-term emotional psychological effects. Very important concept that we're beginning to come to in this country.

We learned other things about triage and separating the sick from the less sick at the emergency room door. And we learned that people who were severely ill on scene were unlikely to survive. Part for transportation reasons and part for equipment and training reasons out on the scene. We learned that very small numbers of people have truly life-threatening events. The three percent is still very much the rule here. And so we know now that separating the minimally ill from the critically ill is a very important part of the process so that we can direct our attention to the critically ill. A small number, but we need to do that. Triage is the word.

MODERATOR: Whereas the others, the minimally ill will -- largely speaking will recover with minimal treatment as well.

URBANETTI, J.: Yes. Yes. Exactly true. Now longer term. We have some other information that keeps coming to us about the long-term effects with respect to Tokyo, but the long-term psychological effects turn out to be very much the larger part of the problem. Long-term medical effects with this particular substance, minimal. Minimal. As a military weapon, it was most effective in the short term.

MODERATOR: Right. Right. And our system clears it rapidly.

URBANETTI, J.: Doesn't create long-term effects.

MODERATOR: Right.

URBANETTI, J.: But we'll talk about some differences between the military nerve agent and commercial nerve agents in the next few minutes.

MODERATOR: Okay. Let's talk a little bit about the risk to healthcare workers and first responders in this situation and what we learn from that.

URBANETTI, J.: First responders, whether they are the EMS teams or fire or police, and medical personnel have risk that comes from whatever chemical is carried to them. And that risk is interestingly enough most often an inhalational risk, a breathing risk rather than a touching risk. The job of skin is to be a wall. The job of the lungs is to let everything in. And so most risks are inhalational risks.

MODERATOR: And of course, fire departments around the world know this in every day work.

URBANETTI, J.: Fire departments are smart. They've worn masks since really the '70's on a consistent basis. And police departments generally are not immediately involved in the area in any case, and so their risk is relatively low. But medical personnel have a danger and a risk whether they're EMS or whether they're at the emergency room. That depends in part on the particular substance. And the greatest danger and risk is inhalational.

MODERATOR: And a very high number, it seems to me. Roughly 25 percent of the staff there at St. Luke's did have evidence of toxicity contamination.

URBANETTI, J.: People came in. Patient's came in. Were not cleaned. The word is decontaminated. And store it all together in that one room. 25 percent of the nursing staff that worked in that room became ill because of the materials coming off the clothes.

MODERATOR: Right. Which not only effects their health but effects their ability to provide emergency care for the --

URBANETTI, J.: Rule number one in the business of emergency care is protecting yourself. If you get sick, you're out of the practice and somebody's got to take care of you. That's a big waste.

MODERATOR: Right. Are public health professionals prepared for an event of this magnitude in this country? Do we have the kinds of drills and practices in place that we need to prepare?

URBANETTI, J.: I think if you asked that question five years ago my answer would be not only no, but hell no. [laughs] We've come to recognize I think that public health, that planning and preparation is critical to responding. And probably a good example of this is to understand what we do with heart attacks. We have large numbers of people now trained to provide life support anyplace that's required. The time to plan and train for that is not when the person falls down in front of you.

MODERATOR: Right.

URBANETTI, J.: But to have had some understanding, practice, and training before hand. You need to do that before the event. And that falls squarely into the realm of public health and public awareness. Today, that focus, that concept has gotten very thoroughly into public health training programs. And I think we're seeing the benefits.

MODERATOR: And what specifically can the public health training program do to help prepare us for the chemical risks that might affect our communities?

URBANETTI, J.: Chemicals risks are predictable. It is relatively easy, straight forward, and in fact most communities already do this. Look at the risks by what's called a hazard vulnerability assessment. What's stored in your community? What kind of preparations have been made to respond to an accident with that stored material in that community? And fire departments are very expert at doing this. Public health department needs to understand that as well from a training and planning perspective. Materials that travel through, whether it's through roads or by train method are documented in terms of what they are. And understanding marker systems and what is coming through is a very important part of this. And the NIOSH team has some guides that make that point very clearly. Use of protective equipment, which is a new idea to hospital personnel. An old idea to fire department and hazardous materials people, but a new idea to hospital personnel. Has to be part of the training planning program. And public health pre-planning plays very much into that role.

MODERATOR: Right. So to link those first responder agencies to the hospital system is a responsibility in many ways of the public health system.

URBANETTI, J.: Exactly. And federal government money is going into that even as we speak.

MODERATOR: Right. And NIOSH has guides on the actual chemicals as well as the hazard preparations for each of them?

URBANETTI, J.: There's some very good text out of that government structure that help us understand risks of the materials and how to best deal with them if there's an exposure. Right.

MODERATOR: We've talked about some of the large-scale events in Tokyo, Bhopal and potential chemical tank car accident for instance. Let's talk a little bit about some of the commonly used chemicals in our communities that we should be aware of as individuals and as public health professionals.

URBANETTI, J.: Remember that first list, Peter, that we showed that went through a number of what we called then, and I'm going to call now, industrial chemicals. Very important list. Probably top of that list is what the military used, nerve agents. Military developed some materials that do damage to how nerves work in the body. Those materials were in fact first developed by scientists looking for bug spray.

MODERATOR: Oh, is that right?

URBANETTI, J.: And you'd made that comment when you looked at that list of chemicals as well. That many of these things are chemicals that we see or have seen recently on the open market as bug sprays. And the original military nerve agents were developed originally as bug sprays. They are terrifically toxic to bugs. They also happen to be terrifically toxic to people. As our today's bug sprays. Toxic to people if enough gets into you. And so in places where commercial bug sprays, crop dusting processes go on, medical danger comes from accidental exposure to those materials. These are the principle chemicals that we have an antidote for. We have treatment for. And it's wonderfully exciting to understand that, because a little bit of knowledge about nerve agents, how to diagnose the illness, and how to treat them fixes these people. And to put that another way, the Israelis during the original Gulf event some years ago were very much worried about nerve agents being used by Saddam Hussein. So they planning, trained, and practiced. They trained even 14-year-old children how to identify the illness and how to treat the illness. Very important concept.

MODERATOR: Let's talk about some of these chemicals in specifics. And first, cyanide.

URBANETTI, J.: Cyanide, even though we don't hear much about it, is one of the most commonly used, stored, and manufactured chemicals in this country today. It is widely stored in both liquid and solid format. Cyanide is a very important chemical for some agriculture processes, for metals handling, and for plastics manufacturing. And consequently, one of the problems we run into in the fire that involves plastic will be a cyanide exposure. Large quantities of this material.

MODERATOR: And it's widely used throughout manufacturing and agriculture, photography, everything.

URBANETTI, J.: You bet. The cyanide comes in two forms, as I said. It comes as a solid, and it comes as a liquid, which make it up into the air. When it gets up in the air, cyanide gas, the only seriously dangerous material that is lighter than air. All other seriously dangerous, breathable materials are heavier than air, sent down. But this one gets up. That's one of the reasons why it wasn't very effective in World War I, because it blew away.

MODERATOR: It dissipated in the air.

URBANETTI, J.: And consequently, you couldn't develop a large enough quantity unless you put it into a small room, as we have for years. Execution chambers, gas chambers use cyanide as the gas, because it's a small controlled area.

Cyanide smells characteristic a little like bitter almonds. But half of the population, half of the normal people in this world genetically can't smell that. So we don't have a good warning tool in many of the people.

MODERATOR: I see.

URBANETTI, J.: And you may have an exposure and just not know that the exposure is happening. If cyanide is breathed in and the dose is low, then they'll be some problems with confusion and some difficulties with maybe some nausea or vomiting or breathing quickly. But at a low amount coming into the body, death rarely occurs. Unless it's continued for a period of time. The body actually has its own cleanup mechanisms for cyanide. But high quantities of cyanide breathed in like gas chamber quantities of cyanide create death quickly. It interferes with oxygen being supplied to the rest of the body. And within minutes an individual may collapse and die as a result of cyanide exposures. That acute inhalation is important from a medical perspective because breathing in cyanide in a simple sort of way either kills you or it doesn't. So by the time people arrive at a hospital, if they're alive, chances are they'll do very well.

MODERATOR: Right. Because I see on the slide that in zero to 15 seconds you're picking up the hyperventilation and then seizures in less than 30 seconds often. That impact is going to be -- is dramatic in almost an instant.

URBANETTI, J.: Cyanide is an interesting substance just because it makes the brain take deep breaths. Some people will say that that's one of its reasons for use in a gas chamber is because the person sitting there knowing cyanide's coming can't hold his breath. The very first smell triggers very deep breathing, and the chemical gets in very quickly.

MODERATOR: I see. Sows the seeds of his own success, so to speak.

URBANETTI, J.: There you go. Right.

MODERATOR: And then pupils are dilated and there's an absence of cyanosis so that there's all these affects together.

URBANETTI, J.: Cyanide exposure may be a little tough to identify and sometimes the medical people get confused about that. The Tokyo subway event was first thought to be cyanide until some information came down to say no it wasn't cyanide. It was actually nerve agent. Cyanide is an inhalational exposure. It's a pretty uncommon problem. But more common problems are the ingestion cyanide. Cyanide salt. And there are a number of circumstances where the cyanide salts have been ingested. Sickness then comes over a period of hours. Long enough time delay so that medical professionals have a chance to do treatment. And so there are specific treatments for cyanide. That ingestion issue was one that presented what I call one of the most expensive terrorist events ever in this country. You'll remember back to 1982. There was an episode in the Chicago area of cyanide being put in Tylenol capsules.

MODERATOR: I remember it very well.

URBANETTI, J.: And there were a number of deaths that occurred because of that. But as a result of that event, first time ever a toxic material being put into a commercial product and then put back on the shelf. As a result of that, we developed the whole science of super-packaging.

MODERATOR: Right.

URBANETTI, J.: And so by some calculations, ten to 15 billion dollars a year in this country go into packaging in sole response to that event in 1982.

MODERATOR: Right. Well, anybody in our audience who, like myself, was involved in public health agency at that time well remembers what it was like to get thousands and thousands of phone calls from totally panicked parents and non-parents around the country who were wondering what the heck they were supposed to do with the Tylenol on their shelves or what they were supposed to give their children and so on. So --

URBANETTI, J.: You just made an extraordinarily, I think, important point, too. That the reality, the medical reality of an event may be one, two, three deaths. But the public perception and the angst that surrounds that is an extraordinary size and importance and one that I think requires much of our planning and preparation to try to deal with that other part of whatever problem.

MODERATOR: Right. And it's almost certainly why the public accepts the notion that they're going to pay extra for that packaging prevention, I guess. Let's talk a little bit about some of the other major intoxicants that you have listed out here for us. And we can go through them a little bit.

URBANETTI, J.: We've mentioned a few, because it's my favorite, pulmonary intoxicants. World War I first weapons out there were gases that one might breathe in and have trouble with. Each of the substances on the list here are common, widely stockpiled in large quantities with problems waiting to happen. And understanding how those problems might occur, pretty useful I think. The problems for each of those agents are first, that they can be a little irritating to eyes and to nose. But over a period of time, they can do some very important damage to the respiratory track generally. And those delayed effects are among the more important. Sudden, within minutes effects and then delayed four to ten hours to twelve hours later effects are very important. Because between the two, the sudden effects and the delayed effects, an individual may look and even feel normal. He may be seen by the medical system during those normal hours.

MODERATOR: Right.

URBANETTI, J.: Sent out, and then some hours later become very ill or even die. And if he's out and in an unsupervised setting, we've missed the opportunity to provide healthcare.

MODERATOR: So is that what you mean by treatment should be supportive in that period?

URBANETTI, J.: And so during that period of time, at the very least we need to continue to observe the individual, look for things that are about to happen, and to be prepared for them so that the individual's in a controlled setting.

MODERATOR: So you're staying in contact with him or her and able to respond (Indiscernible). What about phosgene. I've read that in this country we produce and use over 300 thousand tons a year.

URBANETTI, J.: Phosgene is a very simple and important chemical, because it has chlorine as part of the molecule. And chemists like to take that chlorine -- it moves easily -- and attach it to other things. And the other things that get worked on and built from phosgene are very common foamed plastics as the most common use of phosgene in this country. Foam plastics used, built from phosgene, if you turn that construction around and you burn them, then phosgene becomes and is a very common fire-related exposure issue. Important substance because phosgene doesn't smell bad, and we'll make that point a little later on. But because phosgene doesn't smell bad, people may unwittingly have larger quantities get in and consequently have long-term effects without understanding the process.

MODERATOR: Right. The smell does not drive them away.

URBANETTI, J.: It's a very pretty smell. It smells like new mown hay or freshly cut grass.

MODERATOR: Right. And it's heavier than air I understand.

URBANETTI, J.: Like all of our other potentially toxic substances, with the exception of cyanide, it is heavier than air, sinks down, very effective in World War I because it sank into the trenches. Farm boys in World War I thought it reminded them of home. So often they wouldn't put their mask on.

MODERATOR: Wow. And what are the health effects of phosgene inhalation? Phosgene, if it's inhaled, when it contacts the very smaller airways in the lung, does damage to the lining cells of those airways. And those cells separate air from blood. As the lining cells are damaged, fluid leaks from the blood vessels into the lung. At first in very small amounts, and then progressively over hours in larger and larger and larger amounts. So that an individual may look and feel well, and then four to six to ten hours later suddenly have very large amounts of fluid in the lungs known as pulmonary edema. The word we use in medicine is adult respiratory distress syndrome. There are many different illnesses that create that problem. That problem, once it develops, has a death rate of anywhere from 30 to 60 percent in this country today, despite our best efforts. So understanding its process is important.

MODERATOR: And understand that it does not respond to the normal drugs we use in our arsenal to reduce fluid in the lungs.

URBANETTI, J.: Interestingly enough, I just described fluid leak into the lungs. And that fluid leak into the lungs can be up to two liters an hour in terms of quantity. Huge quantities. Those two liters have to come from someplace. It comes from the blood system. Makes the person have low blood pressure. Makes them appear to have lungs that sound and look wet. And often, medical responders will give drugs to remove fluid. Byproduct of that is fluid doesn't get out of the lungs because the disease doesn't get better. Fluid is already low in the blood system.

MODERATOR: Further collapses.

URBANETTI, J.: And consequently there's further loss of blood pressure. Serious complication.

MODERATOR: I see. I see. So it masks the right treatment in effect.

URBANETTI, J.: You bet.

MODERATOR: Moving on. Let's talk a little bit about ammonia, which is something we all think of all the time. And there's a dry ammonia, which is particularly important to talk about and used illegal methamphetamine production. Is that right?

URBANETTI, J.: Exactly. Now we all have some ammonia experience. You know, we all try to clean our windows and things of that sort. It's a very pungent substance. And as long as our exposure is relatively low, we've not had much trouble. We have occasional problems, unfortunately. And, in fact, now more frequent with ammonia stored in houses, youngsters drink it and have damage to the back of the throat or that it may splash some in their eyes. And because of its characteristic, it penetrates tissue very quickly. And it's once into a surface very difficult to remove. That's ammonia with water base to it. Relatively all amounts. Ammonia without water, called the anhydrous ammonia, used primarily in this country by farmers to add nitrogen to their fields.

MODERATOR: Uh-huh (affirmative). To the soil. Right.

URBANETTI, J.: And large quantities of anhydrous ammonia are found in almost every community that does any farming at all. And there are some risks associated with that, but actually, interestingly enough, probably the biggest risk is to people who steal some of that anhydrous ammonia and use it to make methamphetamines. That's one of the precursors in the progress or development of a chemical facility to make methamphetamines. It can be done. It can be done in the backseat of your car.

MODERATOR: Which is why that particular drug of abuse choice is more popular in the middle west, because the source of that chemical around large farms. Right?

URBANETTI, J.: Exactly. Exactly correct.

MODERATOR: I see. And what exactly is methamphetamine? It's --

URBANETTI, J.: Now methamphetamine is a chemical substance very much like -- In fact, Sudafed. And often it's made out of Sudafed. Chemical substance that is a stimulant. And it's a stimulant that was used by many countries in the 1930's and 1940's, particularly by military people to be awake and alert in the middle of battle. And then it's addictive possibilities and some other longer term damage became clear, and it's come away from its marketability. Similar chemicals used for a long time and still today for ADD issues. You've heard of Ritalin and chemicals like that.

MODERATOR: Right.

URBANETTI, J.: Very much like the methamphetamines.

MODERATOR: I see.

URBANETTI, J.: They are stimulant chemicals. Used under some control, they have some safety.

MODERATOR: Right. Right. Let's talk a little bit about the specific negative health effects of ammonia exposure.

URBANETTI, J.: Ammonia exposure as a skin exposure, fairly easy to deal with even at high doses. But as a respiratory exposure, a bigger problem. Again, in a similar way to phosgene, long-term delayed effects of airway irritation and airways that are irritated, often become infected secondarily, and so problems of secondary pneumonia become very much a part of that.

MODERATOR: And then let's move onto chlorine gas, which is used industrially, but it's also commonly trucked through our communities, both the rail and regular trucking on highways.

URBANETTI, J.: Well, we have a lot of experience with chlorine as does most individual in the United States. Chlorine, first damaging gas used in World War I. Very effective gas if you don't have a mask on and in place. Chlorine is the number one gas reason to go to any emergency room in the United States today. Of all gas exposures, chlorine is the number one. But interestingly enough in the United States, we don't see very many deaths from chlorine. And you might ask why. And the reason is because it smells bad. People are not stupid. If they smell something bad, they go away. Phosgene as an alternative doesn't smell bad. People don't avoid it. But in any case, chlorine in low quantities smells bad, irritation of eyes and nose. If you can't get away for some reason, you're stuck in a room or something of that sort, then the amount of exposure is higher. And the same delayed lung troubles will occur with chlorine that we've described with Phosgene and with ammonia.

MODERATOR: So our challenge is to obviously reduce exposure in the first place and prevent that kind of leak that can have those effects.

URBANETTI, J.: Indeed. I mean, we'd like to avoid that or at least make people sufficiently alert so that they know such things as don't make your own chlorine. Mixing bleach with ammonia in your toilet bowl to clean it is not a smart move and creates much of the emergency room visit.

MODERATOR: Is that right?

URBANETTI, J.: You bet.

MODERATOR: Self-induced home exposure.

URBANETTI, J.: Yeah.

MODERATOR: Before we go on, I'd like to remind our audience that we're going to be able to take questions in just a few minutes. And you may call us at 1-800-452-0662 or send your questions by fax to 518-426-0696.

Can you summarize for us what public health professionals should do to be better prepared for chemical hazard events?

URBANETTI, J.: Chemical hazard events occur with regularity. And they are very treatable. First, like everything else, the treatment best is avoidance in the first place. So preparation and planning needs to be done. Awareness of chemicals in the community that transport through the community, understanding what they are, a little bit about their quantity is the first step.

Then, preparation for immediate response. The fire department and hazardous material teams have practiced this for years. They're terrific at the business of containing and providing perimeter support for an event. What we don't do well is train and practice at the medical response level for a large-scale event. And that, in my opinion, needs to be done. That's the role that the public health department is coming to play much more actively now. The preparation, planning, training aspects.

MODERATOR: Well, here's a question that relates to the treatment issues that you suggest here from a fax from Albany. You mentioned that patients exposed to phosgene inhalation do no respond to drugs that are intended to reduce fluid, as we discussed earlier. How should they be treated? And is this commonly known by first responders the appropriate treatment?

URBANETTI, J.: I'll reverse the question. But try to respond to it. I believe that this is state of the art therapeutic intervention for any of the substances that we've talked about that have delayed pulmonary edema effects. Awareness that there can be a period of time when a person looks normal and that there will be rapid development of illness up to and including death. Point number two, that as that illness develops, the first awareness of the illness is the patient's own statement that he feels short of breath. Patient's sense that he has shortness of breath is much smarter than any of the tools that we bring. He will have shortness of breath before an x-rays is changed, before a blood gas abnormality shows up, before sounds appear in the chest. So we must think about that. Patient to be watched for a period of four hours. And if illness develops, number one, not to remove fluid by diuretics. Number two, use of a tool that is increasingly finding a role in emergency rooms around the country and in fact Connecticut, even in many of the ambulances now, positive airway pressure. Application of a mask with positive pressure. Very much like the Air Force pressure masks for oxygen has become a very important tool in early therapy of the wet lung or the pulmonary edema lung. And there is now good evidence that early use of this in an individual who's developing a toxic inhalation-related wet lung has value. If that's insufficient, then that person goes on to get attached to a ventilator and even more pressure gets applied. We don't have a chemical fix for these exposures. There's no magic bullet for them. I mean, all we can do is provide supportive care during the time of the illness. But early awareness and identification of the disorder and then applying the mask is useful.

MODERATOR: I see. I have a couple of other questions, but let me come back to the summary of the chemical hazard preparation that we talked about before. And we have a couple of slides that I think are important to touch on, particularly the chemical risk assessment in a community.

URBANETTI, J.: The community chemical risk assessment has already been done by your fire department. That's part of their knowledge collection, because they're the first responders to any event in the community. But sometimes that chemical risk and hazard data isn't shared with hospitals. Hospitals have, in my opinion, an obligation to know what's out there. They have a way to collect that information, and communities by federal regulation in this country have what is called an LEPC, a local emergency planning committee where fire and police and public health personnel get together to talk about what's in the community. Often this group poorly attended by hospitals, and they need to be better attended. So that's the first move is get the knowledge out there to the people who have to have the knowledge. And then once the information's out there, response to most of these things is really pretty simple. And the training for it and the understanding is really pretty simple stuff. In some countries, Thailand is a wonderful example where the Red Cross is a very effective teaching training tool. They have a medical school. They have a nursing school. A very big organization. And the Red Cross in Thailand teaches weapons of mass destruction, chemical information to the public at large. This is simple stuff to teach if it gets done in a uniform fashion.

MODERATOR: I see. That's interesting, because one of the questions we got faxed into us talks about the use of gas masks to the general public awareness. And weren't there some case in Israel where the people died from using gas masks incorrectly, putting them on during the Gulf War in 1991 the wrong way?

URBANETTI, J.: That's terrific and a very important point to make. And that wasn't just during the Gulf War, but that's happened repetitively. One of the points I make with respect to military stockpiles. We have never lost a person to a gas release in any of the military stockpiles. We've lost numbers of people to improper use of the protective equipment. That's a teaching training point. Same point was made in Israel. If gas masks were handed out to the public, there was very little teaching training on how to use them. There were some older people. I'm getting older, so I guess I can say that. There were some older people who put the mask on, forgot to take the plastic cover off the filter, and so the mask was on. They weren't able to breathe. They're having trouble, and they thought that that meant that they'd already had an exposure so they didn't even take their own mask off.

MODERATOR: I see.

URBANETTI, J.: So they up and died in the middle of improper use of equipment. No deaths from chemicals. But deaths from inappropriate or improper training and teaching.

MODERATOR: So knowing how to chose and use your personal protective equipment is the critical matter, right?

URBANETTI, J.: Abundantly clear. Simply providing the protective equipment is the very smallest part of any kind of program to help the public.

MODERATOR: Right. But it's a combination of public awareness and receptivity to that training, I'm sure, is an extraordinary problem when you look at this country. Issues like duct tape and plastic over your doorways to prevent inhalation assaults.

URBANETTI, J.: One of our problems in this country is that we have large numbers of experts in many subjects, all of whom might find themselves contradicting each other. So the public at large has trouble identifying a responsible and knowledgeable group. That's where one of the places that public health department will come out.

MODERATOR: I was going to say, can you then give us some of the resources that you think are good for this kind of information? I know you've got a slide prepared with NIOSH and EPA and other resources.

URBANETTI, J.: The listed resources here are resources that give us very good background, chemical and biologic and in fact radiologic exposure data. These are very useful resources. I commend them to you.

MODERATOR: And so you have NIOSH and EPA as well as the USAMRID.

URBANETTI, J.: That's the U.S. Army Medical Research Institute for Infectious Diseases. The U.S. Army pretty much has the handle on the clinical material for chem-bio and nuclear exposures. In part because of accidental events, and in part because of studied experiments put on in the '50's and in the '60's. The information that's available from the military -- Probably important to make a cautionary point here -- is information that's been collected mostly in 20 to 40-year-old males. And consequently, how chemicals or biologic events interact with 80-year-old hypertensive females may be a different issue and one of the reasons why we need to understand this better.

MODERATOR: Okay. I'm afraid we're going to have to close it there. I would like to thank you very much, Dr. Urbanetti. Is there way that public health personnel can contact you with additional questions or for more information as a follow-up on this discussion today?

URBANETTI, J.: I'm happy to provide my e-mail address, and although I may not get back to you within an hour or two, I'll make every effort to provide support.

MODERATOR: Thank you very much. I'm sorry to cut you off, but we've run out of time. I guess our conversation went on too long. I'd like to ask our audience again to take a moment to fill out your evaluations and send them back to us at the University at Albany. Your feedback is invaluable in the development and funding of our future programs. Thank you very much. If you have any topics or speakers you'd like to see on a future program, we welcome your suggestions. Today's program was presented by the University at Albany's Center for Public Health Preparedness. Please feel free to contact the center with any further questions on this topic or to request video tapes of the program. This program will be available online by a web streaming in two weeks. Please check our website for further details. I'm Peter Slocum. See you next fall with the University at Albany's Center for Public Health Preparedness Grand Rounds. And thanks again very much to Dr. John Urbanetti.

URBANETTI, J.: Thank you Peter.

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