An attack by any other name...

An attack by any other name...
Small plane was intentionally flown into a building housing a Federal IRS institution. CNN and MSNBC both are reporting the same story. Both sites are featuring video with eerie resemblance to 9-11. Authorities are, once again, quick to note in staunch "nothing to see here fashion" - we have no reason to believe this is a terrorist act -
Perhaps its a matter of not connecting the dots...
Lets connect a few:

• Man writes suicide note on website
• Man proclaims anti-government rage and 'violence the only solution'
• Man sets own house on fire then flys private plane into building (IRS, CIA and FBI all have offices in the complex where the building that was struck is located)
•  
• And the official speculation is...

"At this time, we have no reason to believe there is a nexus to terrorist activity."

 What? Maybe we have forgotten the term domestic terrorism, forgotten about government buildings as targets (soft ones). And maybe we've forgotten about places like Oklahoma City and the Murrah Federal Building.

Wanna see my mucous plug?

My Little Mucous Plug

Wanna see my mucous plug?

If you've been listening to the podcast or within the sound of my voice, you know I've been sick with a little chest cold...and annoying cough. Well the other day I coughed this mucous plug out of my (left) lung.

Note the retained shape of the bronchi and smaller airways (at the top left of the picture).

Close Schools, No Food

Close Schools, No Food?! What? MSNBC is running a story along with several other web and mainstream media talking about various fallout from the winter storms that have hit the Maryland/Virgina/D.C. area.  Living in Western NY, it is somewhat difficult for me to understand how 2-3 inches of snow can close an area down. (I don't bother to shovel the driveway until we get 6 inches of snow!) With that said, this storm dropped more than 2-3 inches; it left 30-35 inches of snow on areas that are not geared to deal with it. That much snow is a show stopper no matter where you are. But the snow is not the point of today's post.

Among the various secondary impacts is the fact that schools are closed and therefore, kids are going hungry, leaving families without any food.

"The two snowstorms that pummeled the region, leaving more than 3 feet of snow in some areas, deprived tens of thousands of children from Virginia to Pennsylvania of the free or reduced-price school lunch that may be their only nutritious meal of the day...."

I can understand the need for reduced price or free lunch programs and support the effort. However, I have to ask how this situation is possible...if you don't go to school, you don't eat?! This snowstorm was predicted well in advance and nobody took the time (knowing they need the supplemental food from schools) to act in advance? To be even a little pro-active...just a little?

The article goes on:

"...about 43,000 children are eligible for free or reduced-price lunches. Some also get breakfast, dinner and bags of staple foods to take home for the weekend."

Okay, I can buy the fact that poverty in America is worse that most would like to admit. But to say that kids and by extension, families, will go hungry because the schools are closed is almost unbelievable...I said almost.

So, lets ask a few questions...

• What do you do when a kid is sick and stays home from school? No school, no eat. Right? 
• There is no mention of routine absentee rates or drop out rates in the schools. A quick Google search indicates that, if you're not going to school you're not eating...there must be a lot of hungry kids. Even before the snow storm hit. 
• How about this...What the heck do these kids do during school breaks and summer vacation!?

I'm sure to get some interesting emails on this story, so let me be sure to state some level of understanding that this storm would be equal to an earthquake occurring here in Rochester, NY. It's simply not an eventuality we worry about...just like 30+ inches of snow is not on the top list of threats in the State of Maryland. Yet, I have to wonder why a predicted snow storm can close a major, well funded, well outfitted city, like Washington, D.C., for two weeks...shouldn't we be able to recover a little better?

I also wonder what will happen when the money dries up and the public assistance goes away? Where would this go if it were a prolonged (months, not weeks) worth of natural disaster...Haiti style. But that can't happen here. What all this leads me to is an in-your-face reminder about the population living on the edge here in the most prosperous nation in the world. It's also a reminder that the Ripple Effect of a situation can be just as bad, if not more devastating that the original catalyst event.

When it comes to domestic preparedness in this country, we should point to the map and say "lets pretend this is a country in need of our assistance..."

Swine Flu Numbers

These numbers brought to you by the letters H and N

The debate on weather or not Swine Flu will be a factor as we continue into 2010 continues. Here are the current estimate numbers from the CDC. The cumulative estimates for the 2009 Swine Flu (H1N1 for those wanting to be politically correct) indicate that nearly 11,700 people have died from H1N1. This includes 1,180 children. Keep in mind that seasonal influenza kills 35 to 40,000 each year in the United States. The bigger impact may be the number of illnesses related to the virus...an estimated 57 million (out of about 300 million population) Americans have been sickened.

Doing Decon

There have been several instances in late 2009 and early 2010 that highlight the need for emergency decontamination at health care facilities. People contaminated with a hazardous material showing up at random to emergency departments or other health care location poses untold risks to the health care provider, the facility, other patients, and the community. A recent such event at a walk-in urgent care clinic underscored these risks. With the number of walk-in care, urgent care and retail health clinics growing, the issue of emergency decontamination needs to be revisited.

Lets start with the understanding that there is a difference between chemical, biological, and radiological contamination. Chemicals and radiological material is perhaps the most concerning as the longer the material remains in contact with the person, the greater the exposure and subsequent effects will be. Also, if externally contaminated the person may be able to "off gas" or spread the contamination. With chemical materials off-gassing can cause serious inhalation and mucous membrane irritation and secondary contamination in other people. The facility can likewise become contaminated. The spread of radiological contamination has a higher risk of secondary contamination...although the onset of effects will most likely be delayed...and the possibility for occult contamination and extended cleanup measures will be needed. Biological contamination can take the form of a person ill with a disease (flu) or the presence of disease containing solid material...like anthrax in a powder. We should point out here that a difference exists between exposure, contamination and reasonable risk. Exposure simply means you've come in contact with something and may or may not suffer from it. When we talk about exposure we usually are not overly concerned with decontamination unless visible product remains on the person or clothing. Contamination commonly indicates that a residue or material remains on the victim and that material is able to be spread. Contamination comes in two forms...external - able to be spread and internal - not able to be spread. A person who ingests a radiological source most likely would not be capable of spreading that contamination nor would a victim exposed to vapor or gases unless the vapors permiated the clothing. The point is that once a material is inside the body the risk of secondary contamination is much less as is the need for decontamination. Reasonable risk exists when a person has been in an area and, with or without symptoms, is anticipated to have been exposed or contaminated...prophylactic decontamination is warranted.

So, the big question is; who should do decon? At an emergency scene the issue is clear that the jurisdiction having authority in a chem/bio/rad event (most often the fire department) should provide or cause to provide decontamination. The use of low pressure, high volume water streams and improvised shelters may be used in emergency mass decontamination, while specially trained hazardous materials teams may provide a more refined and specific decontamination. The problems begin to arise when victims begin to self-refer to emergency departments or clinics... that is they leave the scene prior to the arrival of traditional responders. This poses a major issue as these victims will likely arrive a health care sites with no warning and no clue as to what they may have been exposed to or contaminated with. When this occurs and goes unrecognized, the health care facility, civilians, and health care providers are at risk. Immediate action will be needed to stave off secondary contamination and serious impact.

Now the question becomes; who should do decontamination at a health care facility? This argument has been going on for years and opinions are highly polarized. One opinion often held by health care organizations is that the local responders will not be able to provide decon services at a hospital during such a large event. This camp believes that hospitals must be able to provide decontamination on their own for a period of time. Still others believe that traditional responders will be able to provide protective services to health care sites by way of mutual-aid from surrounding departments. Both points have concerns. First, how do we expect health care providers, security staff, environmental staff, or others to provide decontamination at a health care site? This is often the pool of personnel that is called upon to take training and carry out the functions if needed. The concerns however, loom large. Who will carry out the duties of those assigned to decon? Will the people mentioned above be able to retain the training information and function in protective clothing, including self-contained breathing apparatus? These issues are just the tip of the iceberg.

Second, while many hospitals in the nation have added some type of decontamination shelter or system to meet requirements most, if not all walk-in care, urgent care and retail health care centers have not. As more and more people turn to these clinics rather than emergency departments for routine care, we must realize that the same level of preparedness must exist for these locations. In the non-hospital clinic setting the need for trained traditional responders doing decon operations is even more vital.

Another issue is the logistics of preparedness for decontamination. Tents and shelters must be trained on and practices with. They must be maintained and checked. Self contained breathing apparatus must also be maintained and personnel continually re-familiarized with its use. Other logistical items that are often forgotten are water supply, cleaning solution, lighting, towels, clothing and runoff management. It is simply not enough for a health care facility to purchase a tent and believe they are prepared.

To wrap this up, let me leave you with a few take-home points:

• Emergency mass decontamination should be done on site of the event whenever possible
• Hospitals need to be prepared for self-referrals who may be contaminated and that self-referrals can pose a serious risk
• Traditional and non-traditional responders must be able to recognize the incident indicators of chemical/biological/radiological exposure
• Keep in mind that simply removing a victims outer clothing can remove 85 to 95% of contamination
• All victims being transported by ambulance must be decontaminated prior to transport regardless of triage score or severity

BOTOX: The next bio terror agent

Several mainstream media outlets have been talking about BOTOX...the cosmetic version of Clostridium Botulinum or botulism as the next possible biological terrorist weapon. Also within the past few days, I've recieved dozens of emails looking for information on BOTOX...many asking if this cosmetic botox could be used as an actual biologic agent. So, I thought this would be a good time to review.

What is bioterrorism? Simply put, bioterrorism is the use of microbes or toxins to cause illness or death, or poison the environment. Microbes such as bacteria and viruses could be used as well as toxins. BOTOX is a toxin. Remember, bacteria and viruses cause an infection while toxins result in inTOXication. Bacterial examples include anthrax, plague, and Tularemia. Virus examples include Smallpox, and hemorrhagic fevers. While toxins include botulism and ricin.

What is Botulism? Botulism toxin has several forms; toxin A - G...they are all some variety of Clostridium Botulinum. The cosmetic BOTOX is the toxin A variety and its estimated that it would take a huge amount of cosmetic BOTOX to cause serious biological threat. With that in mind, we have to reinforce the fact that BOTOX is BOTOX...cosmetic grade or pure strength. The symptoms are the same and the lethality is always a potential. In fact, there have been several deaths related to cosmetic BOTOX in the United States. We should point out that there are other medical uses for this toxin. BOTOX can be used to treat muscular diseases. In fact, a tragic case in California has highlighted the dangers of medical botox as a seven-year-old girl who was undergoing botox treatments for her cerebral palsy has died, attributed to the toxin treatment.

Alright, what are the symptoms of botox intoxication? First, you've got to remember that botox is botox...medical, cosmetic or pure toxin. If used improperly, with an incorrect dose, poor injection/administration technique, or intentional exposure to the pure toxin...the symptoms are the same. The general incubation period is 24 to 36 hours after exposure. By the way, estimates are that a single  gram pure botulinum is enough to kill one million people. Botox in general causes weakness, descending flaccid paralysis and eventually respiratory failure. Botox enters the nervous system via the bloodstream, binding to the receptors of peripheral synapses.  Again, all forms of Botox act in the same way...making the point that all forms of Botox have the potential for intoxication and the same set of neurological symptoms. The binding to peripheral synapses stops the release of Ach and the production of AchE.

The specific symptoms are:

• Diplopia or double vision
• Dytharthia, difficulty walking secondary to descending paralysis of skeletal muscle
• Dysphonia or trouble speaking

There are other symptoms that should be addressed; most seriously is the respiratory failure that occurs when paralysis reaches the phrenic nerve and paralyzes the diaphragm. Of note, the Botox intoxicated patient remains afebrile and fully conscious.

Care is mainly supportive...not good news. Ventiliatory support, feeding support and mechanical ventilation may be needed for as little as 6-8 weeks or as much as 7 months.

With all that in mind, Botulinum Toxin being the most deadly toxins known is certainly capable causing thousands, maybe even millions of deaths, with a very small amount. The question then becomes one of production, availability, and dissemination.

Read Fatal Botox Reaction on MSNBC.com
Read Botox as next bio terror weapon in the Washington Post

'Fun-Size' Terrorism

'Fun-Size' Terrorism is not a term relating to an attitude toward terrorism. No, not at all...let me explain;
Have you ever been out on Halloween? Of course. You dress up in costume and go out expecting to get a variety of candy. Sometimes you get back and find out that the candy you got was not exactly what you expected. People dump those fun-size candy bars in your bag, not quite the event you expected but gets the point across.

Well, with that in mind, lets look at our expectations and preparations for acts of terrorism or intentional events. We've been told what it means to live in the "post 9/11" era and how we must be prepared for the next terror attack. Nobody will tell you what the next attack will look like and so we believe and plan for what we've seen in the past...another 9/11-style attack. In short we've fallen into the trap of believeing the biggest or last major event we've experienced is the worst we will ever see. Nothing could be further from the truth! In short, we're preparing (and have been) for the wrong type of event...that's my opinion anyway.

I think we're going to see another attack on the United States and many other sources believe it will be in the not too distant future. While I'm not willing to commit to a time frame, I am comfortable relating my opinions as to what the next terrorist attack will look like. No, I don't think we'll see another attack on the same size and scope of September 11, 2001, rather I think we'll see a "fun-size" smaller and coordinated multiple simultaneous attacks version.  I would also predict that these smaller, coordinated intentional events will be aimed at soft targets...those locations of infrastructure that lack defensive protection or deterrence.

Specifically, I'm talking about locations such as shopping malls, ground transit hubs, health care facilities, sporting events, and hotels and coffee shops. The impact of bombings or other events on these locations...especially if they're coordinated in multiple locations across the country...will have a significant death toll as well as a devastating ripple effect. These smaller attacks will be harder to predict and intercede on. The impact on a community and economy will be huge. Consider the possibility of mass casualty events coupled with a lack of surge capacity or total loss of local hospitals.

The failed attempt to bomb an airliner on Christmas Day, 2009 is an indication that independent individual attackers are a potential threat. Often referred to as "Lone-Wolf" attackers, these individuals may have a loose affiliation and training with well-funded, established terror groups. They may also be individuals with no affiliation but share an ideology or sympathy with terrorist groups. Smaller than coordinated terrorist cells, these lone-wolf attackers could easily infiltrate soft target locations and carry out attacks with conventional explosives, chemicals or even biological materials. As an aside, while the impact of an explosive attack will be huge...the impact of a biological attack (biological bomber style) is almost unimaginable.

McVeigh, Rudolf, and Kaczynski  are all names in our domestic terrorism history that we should keep in mind and even study as a means to appropriate pre-plan and train for what might be ahead. We should also keep in mind the ever-present threat posed by domestic groups; hate groups, supremest groups and Ecological groups. Keep in mind that multiple smaller attacks will be just as devastating as a focused single event.