This study suggests a relative lack of medical training and education with WMD in emergency medicine residency programs in Taiwan. The majority of respondents feel inadequately prepared to recognize and clinically manage casualties of WMD. About 75.0% of respondents were aware of appropriate protective equipment in their EDs. The most common medical equipment mentioned was the use of the HEPA or other specialty masks. Also notable in the responses was the mention of antidotes or equipment for chemical agents and cyanide poisoning. These interventions are not appropriate for biological agents. Standard curricula for training of emergency medicine physicians should be developed and emergency medicine textbooks should be updated to include
information on biological agents that may be used in
a terrorist attack.
In 1984, more than seven hundreds of persons were infected with
Salmonella typhimurium as a result of intentional contamination of restaurant salad bars in Dallas. Gangs of Bhagwan Shree Rajneesh were later admitted to causing the outbreak in an effort to influence local elections.
3 In 1992, a Virginia man was arrested for spraying his roommates with a substance that he claimed to be anthrax. The house was quarantined, and 20 people were given chemoprophylaxis while awaiting test results.
4 In 1994, a Japanese sect of the Aum Shinrikyo cult attempted an aerosol release of
Bacillus anthracis bacteria in Tokyo. In addition to releasing sarin in Tokyo subway in 1995, cult members were also preparing to spread
Clostridium difficile bacteria for terrorist use.
5 During 1998 and 1999, a series of hoaxes in the United States threatened a total of several thousand letter recipients with exposure to
B anthracis. Many of these letter recipients underwent hazardous materials–style decontamination and were given antibiotics for chemoprophylaxis.
6
According to the United States CDC, the risk of an intentional line-source release of
B anthracis in a major US city indicated economic impact of a bioterrorist attack can range from $477.7 million to $26.2 billion per 100,000 persons exposed. It said that early implementation of a prophylaxis program after an attack is essential.
7 Reports released during 1998 by the Institute of Medicine
8 and the CDC
9 have noted the possibility of WMD terrorism and the relative lack of preparedness
among health care providers in managing this threat. All of these documents have identified care providers working in EMS systems and emergency departments as groups likely to come into contact with victims in the event of a WMD attack. It is therefore necessary for emergency care providers to become proficient in recognition, diagnosis, and treatment of casualties caused by WMD agents.
Our country has initiated a process of training in certain major cities but is not expected to reach each emergency care provider. In addition, the current emergency medicine core content
10 and most popular training textbooks of the specialty do not contain specific reference to the recognition, reporting, detection, or management of terrorist disasters involving WMD. There is no standardized curriculum for training of emergency physicians as related to the health hazards of most weapons of mass destruction agents. It becomes the first priority for us to consider how to implement the program and practice into current medical education system and resident training protocol.
Experts believe that recognizing when a WMD terrorism attack has occurred will depend in part on recognizing the increasing number of patients that present with a similar constellation of symptoms. Emergency physicians should pay attention to clinical manifestations and diagnostic clues indicating an unusual infectious disease outbreak associated with intentional release of a biologic agent. Once suspected, we should report any endemic or epidemic events to their supervising health departments. The covert release of a biologic agent may not have an immediate impact because of the delay between exposure and illness onset, and outbreaks associated with in tentional releases might closely resemble
naturally occurring outbreaks. Accordingly, the clues
of intentional release of biologic agents
include
11 1) an unusual temporal gathering of illness; 2) an unusual geographic clustering (e.g., persons who attended the same public event or gathering); 3) patients presenting with clinical signs and symptoms that suggest an infectious disease outbreak (e.g.,
>2 patients presenting with an unexplained febrile illness associated with sepsis, pneumonia, respiratory failure, or rash or a botulism-like syndrome with flaccid muscle paralysis, especially if occurring in otherwise healthy persons); 4) an unusual age distribution for common diseases (e.g., an increase in what appears to be a chickenpox-like illness among adult patients, but which might be smallpox); and 5) a large number of cases of acute flaccid paralysis with prominent bulbar palsies, suggestive of a release of
botulinum toxin. In our survey, 90.0%% of respondents routinely report cases of commercial food poisonings. However, there is still a need to develop criteria and procedures for the centralized reporting of cases suspected to involve intentional contamination or infection.
In case of a WMD terrorism event, we expect that key medical response resources will most likely be overwhelmed. These resources include trained medical personnel, personal protective equipment, isolation rooms, respiratory ventilators, and pharmaceuticals. Of note in this survey was that most EDs staffed by our respondents have only limited negative airflow rooms. As a mass casualty event becomes an increasing threat, frequent check of antedote stockpiles and other medical resources will be essential.
12
Our data does not represent an objective measure of individual physician's ability or
knowledge with regard to WMD agents. We believe that the involvement WMD would not
be limited only in emergency medicine. Although our survey focused on the leadership
of major emergency medicine training programs in Taiwan, we expect that physicians
involving other fields would also feel poorly prepared to recognize and treat WMD
casualties.
The survey has not been independently validated and therefore may include the potential for elements of systematic error related to informational and selection bias. They also include recall bias among respondents. There are also potential variations among the nonrespondents. However, there are no differences in the response between different program types (3 years or one-tier board versus 5 years or two-tier board).
This study strongly suggests that emergency medicine residency programs are not adequately training to respond to bioterrorism in Taiwan. Future efforts should be directed at additional training and education of emergency physicians in residency programs.