Much public attention and government efforts have been devoted to the potential use and consequences of weapons of mass destruction (WMD) by terrorists. Chemical and biological weapons, such as nuclear weapons, are categorized as WMD because their release causes many potential victims, thus overwhelming available resources (1). A successful attack would be devastating. A large-scale chemical attack in a United States (US) metropolitan area would be capable of killing and injuring many people. Regrettably, we live in a world where the use of WMD is emerging as a real threat (2). Although the events of September 11, 2001 have increased our awareness of the risk of terrorism, the threat and existence of attacks with WMD has long been a reality. Several countries have developed chemical and biological weapons, such as anthrax, botulinum toxin, and aflatoxin, for warfare (3). The actual use of WMD for terrorism has been witnessed in incidents such as the 1994 and 1995 terrorist attacks in Japan, where the chemical nerve agent sarin was released, causing numerous deaths and hundreds of casualties, including some health care workers (4,5).
In light of these past events, and the probability that others will occur, it has been recommended that health care facilities and staff should be prepared to respond to the sequelae of a WMD attack (6). These agents pose a threat not only to patients but to health care providers as well. Additionally, training health care providers to use protective gear for treating patients who have been exposed to chemical or biological weapons may also prove useful in situations in which patient exposures are unintentional (industrial accidents) or natural (infectious outbreaks). A recent editorial in Anesthesia & Analgesia highlighted the importance of countermeasures such as the availability of basic decontamination, protective equipment, supplies of antidote, and trained rescue and medical teams that can be made available without delay (7).
Paramedics and emergency department staff are the front line for patients brought to a hospital after a major chemical incident, but they would soon be overwhelmed, and anesthesiologists would certainly be called upon because of their life-support and airway management expertise (7). Additionally, in any case scenario of WMD, anesthesiologists are very likely to be directly involved in either the operative or critical care of victims (8). We believe, therefore, that anesthesia personnel would benefit from a program that teaches how to care for these patients efficiently and safely, while wearing protective gear. In the case of nuclear weapons, although few victims may survive a thermonuclear attack at ground zero, it is probable that many at a distance or exposed to a “dirty bomb” would need medical and surgical treatment. Contaminated victims pose a real threat to health care workers. WMD, as used in this report, does not include every aspect of terrorist activities, such as massive trauma from conventional explosives and munitions. There are numerous well established protocols and resources designed to deal with the sequelae from these types of event (including Advanced Trauma Life Support and mass casualty drills).
Recent studies conducted in the US suggest that many hospitals are not prepared to handle biological or chemical events (9,10). We hypothesized that few US anesthesiology training programs were currently teaching management of WMD-exposed patients as well as the precautions required to decrease the risk of self-exposure. We surveyed all US academic training programs to determine the level of training currently being provided to residents and other anesthesia personnel concerning the clinical management of patients exposed to WMD.
A single electronic survey (Appendix 1) was constructed and made available on the Internet (http://umdas.med.miami.edu/Questionaire.asp). The survey was created based on an exhaustive literature review, analysis of validated WMD surveys (11), informal interviews with experienced WMD clinicians, and input from statisticians (Appendix 1). One-hundred-thirty-five Accreditation Council for Graduate Medical Education accredited US residency programs were identified from the 2003 US Association of Anesthesiology Program Directors Meeting Guide. The programs were first contacted by e-mail, via their program directors and/or chairperson, with several follow-up phone calls for nonresponders. The program directors and/or chairpersons were given access to the survey via the Web site. Responses to the survey were pooled into a database for further evaluation. The names of the programs were de-identified once the data had been collected. Qualitative descriptive statistics were collected and analyzed.
A total of 90 programs of the 135 surveyed responded (67%). Only 33 (37%) of the 90 programs that responded currently provide some form of training or teaching concerning the clinical or anesthetic management of patients exposed to WMD. All of these programs began their respective training only after September 11, 2001. Ten of the 33 have not repeated training in approximately 2 yr. The majority of anesthesiology training programs in the US are located east of the Mississippi River (93 of 135 [69%]). Most programs that responded, and are conducting WMD training, are located in the Eastern part of the US (26 of 93 [28%]) as compared with the Western portion (7 of 42 [17%]). In addition, 17 of 26 (65%) of the Eastern US programs that reported WMD training are located on the Eastern seaboard. The lack of training is further underscored by the finding that only 14 of 33 (42%) of programs with training made their training mandatory, and only 11 of 33 (33%) of these programs had trained all of their residents. Because of the limits of this survey, it is difficult to determine the exact number of total residents trained. However, by looking at the program sizes and numbers reported, we estimate that approximately 900 of the estimated 3700 anesthesia residents currently being trained in the US have had some form of WMD training.
The majority of programs in which WMD training occurred, 27 of 33 (82%), had used some type of classroom teaching. Of note, approximately half, 15 of 33 (45%) of these programs are using simulators to teach WMD management. Only 8 of 33 (24%) offered training in the use of protective gear.
More than half of the hospitals (50 of 90 [56%]) in which the anesthesiology residency programs are located have developed decontamination areas, but only 40 of 90 (44%) constructed or had access to shower facilities. A similar number have chemical protective gear and protective breathing devices available, 49 of 90 (54%) and 36 of 90 (40%), respectively. Twenty-two programs with training (22 of 33 [67%]) resided in institutions that had constructed or provided special facilities for decontamination or resuscitation. The probability of having a WMD training program or decontamination area did not seem to be influenced by proximity to large government installations, nuclear power plants, military bases, major airports, or seaports.
According to the respondents, 50 of 90 (56%) programs have stockpiled antibiotics of some kind. Fifty-two of 90 (58%) hospitals stockpile atropine specifically for the management of patients exposed to nerve agents (NA), but only 23 of 90 (26%) stated that they have stores of pralidoxime (PAM).
Most program directors and/or chairpersons responded to the survey and the results demonstrate that WMD training is found in only 33 of the 90 programs that responded. Of those 33, 10 have not continued with training and have provided no additional training in the last 2 years. Evidence from many training programs (such as Advanced Cardiovascular Life Support) have suggested that, in order to maintain competency, it is necessary to periodically repeat technical training, usually within 6–9 months. Whereas most anesthesiology training programs are located in the Eastern US, proportionally more of those programs actively train their staff when compared with the Midwestern and Western programs. The reason why the Eastern part of the US has proportionally more active training in WMD management is unclear; it may be because the last and largest terrorist event in the US occurred in New York. Another contributing factor may be that many areas in the West and Midwest consider themselves more isolated and thus less likely to become targets. This assumption is clearly challenged by previous terrorist events, such as the Oklahoma bombing. The ability to deliver intense, acute care at the facilities that responded to this questionnaire is illustrated by the fact that 88 of the 90 have level 1 trauma centers. Finally, factors outside the scope of this survey may account for the geographic distribution differences.
Proper training and orientation is essential for the safe and effective use of protective equipment. Evidence from the first Gulf War highlighted the dangers of protective gear without proper training (12). Only 12 of the programs surveyed in this study have any training for protective suiting for their residents and anesthesiology staff. It would be difficult and ineffective to train medical personnel to use respirators and protective suits effectively during an actual event. Routine functions such as tracheal intubation and IV placement are exceedingly difficult and time consuming while wearing protective gear (13). This ability to be able to perform adequately in protective gear is essential because health care workers are, of course, not immune to the effects of chemical agents. This was noted in the Sarin nerve gas incidents in 1995 in Japan, where several health care personnel developed symptoms of exposure many hours after the event in a distant location (4).
We believe that hospital preparedness is critical for any meaningful response to WMDs (14). The hospitals where anesthesiology training programs reside have outpaced those programs in preparedness, as evidenced by the fact that there are twice as many decontamination areas constructed as there are anesthesiology personnel trained to work in them. Although paramedics and emergency department staff may be on the front line in a major chemical warfare incident, anesthesiologists would certainly be called upon to provide care because of their ability to provide life-support (7). In the 1995 Tokyo Sarin incident, a local 520-bed hospital had 640 victims arrive at its emergency department in one morning. Five-hundred-forty-one of those patients who arrived at the hospital did so on their own, thus bypassing prehospital responders as well as decontamination (15). Some hospitals that conduct mandatory training in handling infectious patients, such at those with tuberculosis or severe acute respiratory syndrome, may believe that no further training is necessary. Anesthetic education, however, is different for WMD, especially as regards to protective gear, specialized equipment, and the interactions between antidotes and anesthetics (16).
Regardless of how many anesthesiologists are trained, they are only capable of being effective if supplied with the necessary medications, equipment, and facilities. Fifty-two of the programs responding had stockpiled atropine for the apparent treatment of NA exposures; however, only 23 reported having the antidote PAM available. Although atropine is effective to control many of the symptoms of NA exposure, it must be accompanied by PAM or some other similar drug to allow the reactivation of acetylcholinesterase in the neuromuscular junction. The use of atropine alone would be inadequate in all but the most minor exposures. It is possible that some of these facilities do, in fact, stockpile drugs such as PAM, but that the anesthesiology department representatives are unaware of the supply. However, even if this were the case, it suggests a serious lack of communication and thus preparedness.
This study has several limitations. One major restriction is that we were unable to determine the number of programs that have WMD training, but failed to respond. However, even if every one of the nonresponding programs had WMD training (an exceedingly unlikely scenario) the results would still be alarming. Additionally, although we collected information about various methods of training used, we had no means of quantifying the effectiveness of those methods. The survey was sent to program directors and chairpersons based on the assumption that they would know if their respective hospitals had WMD training programs. It is possible, however, that in some cases their hospitals have such programs of which they were unaware.
As with any untoward event or natural disaster, the time to best prepare is before the occurrence of the event. According to the Director of the Central Intelligence Agency, “it may be only a matter of time” before they [Al-Qaeda] try to attack Americans with chemical, biological, radiological, or nuclear weapons (17). As a profession, anesthesiology should take a lead role in the training all of our personnel. Protecting ourselves as providers is key to maintaining our preparedness and well-being. We believe that at the minimum, anesthesiologists should receive lectures on the management of patients exposed to toxic chemicals, infectious agents, and WMD coupled with hands-on training with the proper use of protective gear (such as suits and respirators) (Fig. 1). Familiarity with basic decontamination techniques and locations of facilities will greatly enhance WMD treatment and reduce the commotion associated with these events. By being well prepared and increasing the awareness of the anesthesiology community to threats posed by WMD, we will ensure better patient safety and reduce the harm associated with these events. Because of the apparent threat of WMD, it seems prudent to have this type of training available at all anesthesiology residency programs. Whether this training should be mandatory and how often it should be repeated is a subject of some debate. Although there has been a marked increase in the training of anesthesiology personnel to deal with a WMD attack since 2001, far greater efforts, including potential involvement of the American Society of Anesthesiologists and American Board of Anesthesiology, will be required to achieve adequate preparedness across the US.
The authors thank Dr. Richard S. Weisman, Director of the Poison Control Center, University of Miami, for his assistance with protective gear and Robert Duncan, PhD, Professor, University of Miami, for his statistical assistance.
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