Arik Eisenkraft, MD MHA, director of homeland defence projects at


Pluristem Therapeutics on general considerations and the overall approach of Israel’s field medical response to chemical terrorism


Let’s get to R


ecent events in Syria involving chemical warfare agents (CWA) and toxic industrial chemicals


(TICs) highlight the need for local and national authorities worldwide to have well established response plans for the possibility of attacks using these agents. Such preparations begin with a


thorough understanding of the threat and with the development of simple and efficient countermeasures. Lessons from numerous training sessions and mass casualty events worldwide have taught us the value of training and implementation of simple response procedures by first responders as well as adequate protection of healthcare providers involved in first response. This led the Israeli authorities in charge of homeland defence to develop a simple yet comprehensive doctrine to deal with any toxicological mass casualty event (TMCE), including chemical terror events. Several tactical characteristics of a


chemical terror event raise important considerations for first responders. We assume that an overt event will be identified early and treated by first responders on site. In the case of a covert attack, however, identification of the attack method may be delayed, thus complicating response and treatment. In this case, health professionals at the second tier of response may be managing diagnosis and treatment, for example in hospitals and community clinics, instead of first responders. Inhalation exposure is the most


likely danger in the event of a chemical attack, with most agents easily absorbed through the respiratory tract, and is compounded by a lack of respiratory protection among the general public. Based on this assumption and the relatively high toxicity of some of the potential agents, we anticipate that such an event will result in a high level of casualties, especially among vulnerable


groups such as children, pregnant women and elderly people. Persistent agents such as VX pose vast logistical challenges, including mass evacuation for a prolonged period of time, complex decontamination efforts, and other safety issues regarding the contaminated area – namely deciding how clean it must be before it can be deemed safe. This further highlights the importance of thoroughly decontaminating victims before they enter hospital premises. First responders should pay


attention to an unusual cluster of signs and symptoms in order to accurately determine the presence of a chemical agent. Once a chemical attack is suspected they should don personal protection equipment (PPE) before treating casualties, based on signs of toxicity. Level C protection gear, including a hood with an air purifying respirator and chemical resistant overalls, should be worn to allow first responders to work efficiently in a contaminated area. With no advanced warning, it is reasonable to assume that the first rescue teams on the scene may be exposed and poisoned. According to our doctrine, emergency medical teams (EMTs) enter the contaminated zone, treat the casualties and evacuate them as quickly as possible.


Identifying the event Currently field detectors are limited in both their diversity and specificity of detection. From a clinical point of view they can be used as a decision aid for confirmation only after suspicion of a chemical involvement has been raised. There are several crucial signs that should alert first responders to the possibility of a toxicological event. These include unusual environmental signs such as atypical smoke or coloured residue, atypical smells, ill or


dead animals and a visible active source. Further indicators could be unusual clinical signs, including fewer trauma injuries than expected, the appearance of similar clusters of signs and symptoms (toxidromes) in otherwise healthy people, and the appearance of those toxidromes among first response teams that arrived unprotected at the scene. Several major toxidromes can usually be defined based on the potential offending agents, which are applicable to most scenarios.


Medical management of TMCEs in the field This scenario warrants a fast and efficient response. That said, any hasty mistake in management might end in devastating consequences with additional casualties, including EMT personnel. So once a toxicological event is identified, EMTs must act according to simple, effective, predetermined guidelines. We have defined a procedure, which is currently used by all first responders in Israel for any TMCE scenario. This simple procedure was shown to be efficient in numerous national exercises and drills, and small- scale TIC incidents. The first and most important step is


to warn all relevant emergency teams and their headquarters. The police should command, control and coordinate with all relevant departments. EMTs on site will immediately put on available PPE, thus preventing secondary exposure, as highlighted in past events like the March 1995 Tokyo sarin attack and the Syrian events in August 2013 and April 2017. The next step is to decide whether


or not the toxic agent is an organophosphate (OP) including nerve agents. It is of utmost importance to distinguish between OPs and other toxic substances, since the former are highly


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