Medical Aspects of Chemical Warfare (2008) - The Black Vault

Medical Aspects of Chemical WarfareINTRODUCTIONIt has been nearly 90 years since the United StatesArmed Forces last encountered chemical weaponson the battlefield. Despite this long respite, images ofpoisonous chemical clouds and descriptions of suddenand horrifying death continue to foment apprehensionand terror. The mention of chemical weapons elicitsoutrage and fear of the unknown. Soldiers confrontedwith even a nonspecific threat of a chemical environmentmust bear the inefficiencies of cumbersome andhot protective garments. Medical personnel face anunseen pathogen and the prospect of managing masschemical casualties they are inexperienced in treating.Chemical weapons are a classic model of weaponsof mass destructive effect that result in substantialcontamination of personnel and equipment. Chemicalweapons are the original weapons of mass destruction,and they are ideally suited as agents of greatpsychological effect. Although the law in the UnitedStates prohibits using chemical weapons against anadversary, this policy is not shared by all nations orby nonstate entities; therefore, to be effective, militarymedical personnel must be knowledgeable and trainedto deal with a chemical weapon attack.In a chemical environment, military healthcareproviders must be:• prepared to handle military and civilian casualtiesresulting from chemical agents;• cognizant of what constitutes a chemicalthreat and the military tactics that could beemployed against the force because theymay be called on to render advice from bothindividual and public health perspectives;• familiar with the acute and chronic medicaleffects of chemical agent exposure in order toplan appropriate medical support; and• knowledgeable of the diagnostic tools availableto identify specific chemical agents towhich their patients may have been exposedand aware of the most effective treatments foracute intervention and prevention of longtermsequelae.The chemical threat may involve overt or clandestineuse of single or multiple agents. Some of these maybe classic chemical agents developed for military applications.Other agents may be highly toxic industrialcompounds that are produced in great quantities andcan have comparable effects; increased interest in thetraining, education, and research of toxic industrialcompounds is now emphasized in both the militaryand civilian populations. Additionally, the adventof more formidable nonstate entities and terroristorganizations interested in the mass lethality and thepowerful psychological effects of these agents hasresulted in an increased concern for the potential useof chemical weapons.Chemical warfare agents need not be lethal to bedisruptive. The resultant mass casualty scenario,psychological effects, diversion of medical resources,need for decontamination, and impairment of fightingability are all desirable outcomes for those thatmight deploy these agents. In a situation where thereare few physical indicators of a chemical attack, themedical practitioner may be the first to recognize theeffects of chemical exposure. An increased incidenceof symptoms consistent with nerve, vesicant, blood,or respiratory agent exposure should raise immediatesuspicion of poisoning. Healthcare providers must befamiliar with the signs and symptoms of a chemicalexposure or the possibility of the combined use ofchemical and biological warfare agents in both militaryand civilian settings.The offensive use of chemical agents continues to bean attractive alternative to some nations and nonstateentities. One reason for this is that chemical agents canbe dispersed over large areas and can penetrate welldefendedpositions. They can be employed againstspecific targets (eg, headquarters control centers) witheffects that include delayed or immediate incapacitation,disorientation, or death.The goal of this chapter is to provide an encapsulatedhistorical overview of chemical weapons, discussthe current chemical threat, and guide readers in theorganization of this textbook.A TIMELINE OF CHEMICAL WARFARE AGENTSEarly Chemical WeaponsThe modern era of chemical weapons began duringWorld War I with the 1915 introduction of chlorine gason the battlefield of Ypres, Belgium. Chemical weaponswere effective in this theater because of the fixed positionsof highly concentrated troop formations. Initiallethal weapons of concern included pulmonary agentssuch as chlorine and phosgene, for which countermeasureswere initially inadequate or nonexistent. As theuse of chemical weapons increased, the gas mask wasdeveloped as an initial countermeasure. The mask wasrefined and improved upon during the course of WorldWar I, and newer models are still being developed today.The use of mustard agent during World War I wasultimately responsible for the majority of casualties2