Bio Chemical Warfare

When the Bough Breaks

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Burned out houses, bombed out cities,

poisoned children in a line,

God is angry, He has said

“Vengeance shall be Mine”.

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A hundred thousand random dead?

Two million random refugees you say?

A paltry tax for them to pay

to no more fear both night and day.

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With warnings and prohibitions,

God’s commandments I made clear,

yet no one seemed to listen,

they scarcely seemed to hear.

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He’s all-loving, all-forgiving,

ever old and ever new,

but lest you burn forever,

do as We say, not as I do.

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We will kill with fire and brimstone,

who’er you are, what’er you do,

so all of you will fear Us

Whether Arab, Copt, or Jew.

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He’s the one and only God,

Syria His Almighty State,

I His presidential messenger;

don’t rock this cradle of hate,

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Ere I poison, maim, or kill

my subjects, old and new,

’til all shall learn to fear

both what We say and what I do.

Rocking the Cradle of Hate

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A few hundred thousand random dead?

A few million random refugees you say?,

A paltry presidential  price  to pay,

for one who fears the dawn each day.

 

 With commands and prohibitions,

God’s decisions We made clear,

yet no one seemed to care,

and scarcely seemed to hear.

 

God kills with fire and brimstone,

who’er you are, what’er you do,

all of you must fear Us

Arab, Coptic, Shia, and Jew.

 

Burned out houses, bombed out cities,

Poisoned children in a line,

God is angry, He has said

Vengeance will be Mine”.

 

He’s all-loving, all-forgiving,

ever old and ever new,

but lest you want to burn forever,

do as We say, not as We  do.

 

He’s the one and only God,

We the God Almighty State,

His anointed messenger ,

owner of all reason and all fate.

 

So We will shower blind destruction

on Arab, Copt, Shia and Jew, 

and all will learn to fear

what We say and what We do.

Radiation: Medical, Nuclear, and Net-Power

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Today , I feel inundated. Outside, the rain, life blood of California, continues. Inside, on the Tube, the mindless flood of misinformation about potential nuclear disaster continues. While hundreds of thousands  of Japanese are displaced from their ruined homes, and thousands are dead and dying  from the tidal wave and the toxic wasteland it created, our  free press  professionals inject yet another dose of  hyped news into the jugular vein of  a fright addicted public:

MSNBC feed  3/27/2011 :14:48 AM ET, this appears;  the precise date and time  offer  a patina of  pseudo science:

RADIATION 10 MILLION TIMES NORMAL AT JAPAN NUCLEAR PLANT!

Then, with no coherent attempt to provide perspective  or describe ‘ normal’ the radiation is asserted to be 1000 mSv per hour, the equivalent to (sic) “29 CT scans according to NBC News Experts.”   Nowhere does it suggest that the 1000 mSv dose requires sitting in the contaminated pool for an hour.  The Expert comparison to 29 CT scans is simply absurd.  It seems clear that scandalous, out of context, ridiculous statements, like  vague, mindless comparisons to past nuclear accidents, sell newspapers, magazines, and TV time, but do not  inform.

On the other hand, we are rarely told  much about radiation from medical imaging. Perhaps our national dosing of medical ionizing radiation is something we are willing to accept for value received. Perhaps it is excessive. But whichever the case, we generally remain as ignorant of one sort of radiation risk as the other.  How infuriating! And how unfortunate that our public comprehension of ionizing irradiation is so little better than it was three generations ago at the dawn of the nuclear age. Was it reasonable to expect our media to inform rather than to merely profit through clever exaggeration? If so, they have failed. “Nucular” or “nuclear,” who cares! Ignorance and fear are the same no matter what its name!  No wonder we may rush to buy gas masks, iodine or KI on our way home from a whole body scan.

We cannot rely on ‘experts’.  And fortunately we no longer have to. The net is there, all the information is there.  As we might infer from significant books like ‘The Wisdom of Crowds’ , people can collectively be less stupid than individuals; now, thanks to the net, we can be well informed about ionizing radiation even if we are not nuclear physicists. We can have, or quickly find, the best available pertinent facts.  Moreover, an order for a CT scan is a prescription for irradiating ionization. It well may be worth the exposure. But both physicians and patients can and should thoughtfully consider the risks versus benefits of prescribed  radiation, and avoid unnecessary exposures.

My introduction to nuclear warfare, thanks to the US Navy, dates back decades. Although the more practical facts of the physics haven’t changed that  much, my knowledge of it, I fear, has gone through quite a few half-lives of attrition. So I had to look to the net for help. The information is all there.  I won’t claim that the material to be found is coherent; it is sometimes conflicting and often confusing.  But that is true of all  pronouncements including those of experts,  because no one puts information out anywhere without a particular view, or even at times a particular self interest. We live in a time when it is within reach of every person, every tweeter, every  web surfer to uncover as many  facts as exist!  I found the information below to be  readily accessible and pertinent:

Tissue doses of radiation are often measured or stated in ”milli sieverts” (mSv), a quantity of ionizing radiation dose absorbed and affecting body cells. While ionizing radiation resulting from nuclear explosions is quite variable due to the number of isotopes and other factors, X-ray irradiation is comparatively uniform, so that mSv are a reliable and useful estimate of risk of most common radiation to people. The numbers are  very useful even when open to argument because of the many variables. Here are some mSv comparisons with an older  tissue dose radiation measure, REMs, or Roentgen Equivalents, Man. (Sorry, women; you have Madam Curie):

• 1 rem = 0.01 Sv = 10 mSv

• 1 mrem = 0.00001 Sv = 0.01 mSv = 10 μSv

• 1 Sv = 100 rem = 100,000 mrem (or millirem)

• 1 mSv = 100 mrem = 0.1 rem

• 1 μSv = 0.1 mrem

(In this essay I use only mSv to make comparisons cleaner.)

Comparative risk of radiation exposure is important and useful both to physicians whose decisions determine the dosages prescribed to patients and to those of us who are exposed to otherwise confusing information and misinformation. It helps to have perspective, which is valuable even when  ‘experts’ argue about precise numbers.  In the much maligned airport screenings, for example, it may help to know that one would undergo:

400 airport screenings to absorb the same mSv as one chest X-ray;

12,000 screenings compares to one mammogram;

20,000 screenings compares to one abdominal CT scan;

40,000 screenings is comparable to one whole body scan;

60,000 to one barium enema; and,

80,000 screenings to one neonatal abdominal CT scan.

Estimates of relative radiation risk from medical imaging, and procedures,  are extremely variable. Yet it is clear that cumulative doses are increasing, and that medical radiation exposure can be significant; whether people disagree by 10 or even 30 percent matters little. The following is a conflation of my remote memory and the harvest from the net today. Here are a few net.ferences:

http://xkcd.com/radiation/ emedicine.medscape.
com/article/1464228-overview;
and
http://www.fda.gov/Radiation-EmittingProducts
/RadiationEmittingProductsandProcedures/Medical
Imaging/MedicalX-Rays/ucm115329.htm.

But the sources are so many, and so easy to access, that for more I will ask  readers to jump into the net and flail about on your own.  I found the accompanying dose estimates of interest. These doses are all in mSv.

Estimated irradiation for medical procedures; Dose in mSv

chest X-ray______________0.1–0.2

each dental X-ray ________ 0.2

head CT________________ 1.5

mammogram ____________ 3

CT abdomen ____________  5.3

chest CT ________________5.8

heart CT and angio________ 6–13

barium enema ___________12–15

angio/vascular study_______19

infant Abdomen CT________ 20

angio/cardiac study ________70

Estimates of average yearly radiation exposure Dose in mSv

background radiation (earth sun, etc) __________________2–3

living within 50 miles of a nuclear power generating plant__ 0.009

living within 50 miles of a coal powered generating plant___ 0.03

daily use of a computer screen or other CRT____________  0.1

commercial full time occupational high altitude air travel____ 2

maximum  allowed annual dose  for nuclear plant workers   _  50

lowest one year dose clearly related to cancer___________ 100

Estimates of acute (or per day) radiation dose Dose in mSv

living within 10 miles of the 3 Mile Island accident____ 0.01

Sacramento to Paris commercial air flight__________  0.085

dose limit for workers in a life saving emergency ___250

one hour next to the Chernobyl meltdown ________300

dose causing transient symptoms______________ 400

dose causing severe radiation sickness or death_ _ 2000

lethal dose_________________________2000–4000

After combing the web, and collating  information from diverse sources, surely I have made errors. So please call them to my attention, dear reader. Let us hope that airport screening will become more rational, and less driven by political nonsense; that unwise dosing of people with medical X-rays will cease; and that the media will act and report responsibly. But hopes are not always fulfilled; we are wise to maintain an informed perspective in case hope fails us.

Anthrax Exposure?

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“I think I May Have Been Exposed to Anthrax”

What happens when someone suspects an exposure to Anthrax? This is a first person fictional account based on a real event. The time, the web sites, and their contents, are very real.

Oct 17, 2001 – At 5:00 p.m., as the office was closing, the secretary to a local judge appeared requesting to be seen for an urgent matter. I knew her to be a very capable person not given to exaggeration, who had always been in good health. Her problem was one I had thought about, but had never expected to face in my own practice. She had opened a suspicious letter and was concerned about anthrax exposure because she now had a sore throat and general aching.

“What did the letter look like?”

“It was hand addressed to the ‘County Court.’ I opened it and some gray dust fell out.

Inside was a weird note.”

“Weird? You mean threatening?”

“Well, I’m not really sure. Yes and no. I couldn’t say. It seemed like a prank,  but a senseless one. It was only about ten words, written in block letters. It was so strange; I just laughed at it and showed it to the law clerk, then threw it out. But as I reflected, it wasn’t exactly funny, and I washed my hands and dusted my desk. That was six weeks ago; I never gave it a thought ’til now. There’s the anthrax thing.”

She and the clerk couldn’t recall exactly what the note said, even after thinking back as hard as they could. It was something like, ‘Cocaine for infidels and harlots. Enjoy.  In Shah Alla.’  There had been no other symptoms, no fever, no other people ill at work, or at home.

“So why are you concerned now?”

“Yesterday I felt tired, and had a slight pressure in my chest., a little cough.  I had some Cipro and started it. It was the prescription they gave dad before he died. I know I shouldn’t have, but I heard that by the time you get symptoms of pulmonary infection it’s too late.”

I’d planned to play poker that night, a game with friends that had been a regular thing with us for years.  My wife suggested I  ‘Bond’ more with Buddies.  And actually i have enjoyed that. But now I, in my own myopic way, was another victim of terror,  and  I sat down, resigned to my fate. At this time of day, the local Health Department was on phone tree answering machine mode. But with this scenario they wouldn’t have done anything at this point anyway. Nor would the police.

Then I remembered the mythic e.net. I excused myself, went to my office, and mounted Browser, my net-horse, settling easily into my Windows saddle for a pixel ride. I would go until I reached a place where a clear decision tree was laid out. I knew that there was some sort of CDC national plan such that local police and health departments were terrorism first-responders. But here there was no longer a crime scene, so I urged Browser on expectantly to What Next.

The local health department did have an electronic information tree. But after a few minutes it became clear that it didn’t yet include bioterror. Employment opportunities. Women’s rights, Babies, Rabies and Scabies were the best there was. “Hell,” I thought, “Why couldn’t it be itsy bitsy mites jumping from the mail? I’ll just  ride on to headquarters, to the top: CDC. “There it is! bt.cdc.gov; bt for bio terror! Maybe I’ll get to poker before the beer is gone.” There was a page of links. And links to links in an elegant chain to… where? I began to click on likely ones. ‘Facts and FAQs about Anthrax. Botulism, Plague, Smallpox.’ Seven pages of them. But it was boilerplate, nothing about what to tell my patient at 5:20 p.m., PDST.’

‘Preparedness; Training; Laboratory issues; Info. Technology; National Pharmaceutical Stockpile.’ There was a phone number for Public Inquiries, another for Emergency Contacts and still others for CDC itself. But this wasn’t an emergency after six weeks. ‘Protocols’ That should do it! I linked to: ‘Interim Recommended Notification Procedures for Local and State Public Health Department Leaders in the Event of a Biochemical Incident.’“Well,” I thought, “at this point I’ll take anything I can get.” But it was actually what it claimed: “Health officer notifies local law enforcement and FBI, then State Health and other response partners per pre-established notification list,” which of course I didn’t have and wasn’t pertinent to a 6-week-old unlikely exposure anyway.

I pushed Browser on to the Morbidity and Mortality Weekly Report where there was a ‘Continuing Education Activity’ based on vol. 49, RR-4, expiring April 21, 2001’. But itdidn’t seem reasonable to take an obsolete e.course at the moment. Besides, the test questions were there, and in large part seemed clearly designed to help justify course perpetuation. But wait! There at bt.cdc.gov/documents/Anthrax etc was:

‘How to handle anthrax and other biological agent threats’. “Whoa, Browser!” After the Do Not Panic section were several scenarios starring powder – containing letters/packages all leading to police or 911. But they didn’t apply after six weeks, no envelope, degraded site. Reluctantly, I headed Browser to the 26-page April 21, 2001 MMWR report entitled ‘Biological and Chemical Terrorism: Strategic Plan for Preparedness and Response.’ No help despite the fancy title.

Then a 15-page ‘National Bioterrorism Preparedness and Response Initiative Report’ of May 8, 2000. Then a 15-page ‘Public Health Preparedness and Response for Bioterrorism’ in which the last entry on a list of upcoming events, ironically, was a Sept 10-11 2001 meeting in Orlando, Florida. By the time I read all that my patient would have died from old age or from anthrax right in my office.

It was clear that the answer to my question – what to do next or where to find the proper advice for this patient tonight – was not addressed. I would have to base a decision on the least wrong thing, most right thing. But isn’t that what every doc does, with every patient, every day?

I decided: Do Nothing.

Back with my patient I reviewed the situation. I advised her again about the extremely favorable position she was in, statistically speaking, without confessing that what happens to a single person can be different from what happens to numbers.  I allowed that she might as well continue the Cipro until I was able to review the case with our local public health officer. I suggested that if asked by people at work, or by her family or friends about risk to them, it was now a moot matter; no one actually had anthrax after six weeks, and the suspect mail was not available. I planned to see her again in a week, mainly to decide about stopping Cipro. Lastly I again explained why testing was not advisable.

She left. I corralled Browser and went to my poker game. I lost.

Oct 18, 2001 – End of story? No. As I had feared, the next morning the chief administrator for the court called about an anthrax test. I was aware that his daughter was a veterinarian, and wondered if he had spoken to her about the advisability of doing expensive and inaccurate tests requiring a number of days to perform, then in the end arriving back where you started, with a decision based on clinical evidence.  After all, vets are far more knowlegable about herd medicine than physicians. We have much to learn. He had talked with her. He understood. She had explained it perfectly. But…

“But doctor, isn’t it possible to just do the test anyway? You know. To allay fears here. And your patient states she isn’t sleeping well; she, too, feels a test would relieve her mind.” There are times, actually more than a few, when it is right to do the wrong thing. I realized this was probably one.

“Of course. Please send her right over. The results will take a few days”.

“But I read in the news that they do them in a few minutes.”

“Well, that is true and not true. There is a test to find anthrax spores in the environment. Or in an envelope, places where contamination is very high. Then there are cultures. First, one looks for organisms like anthrax. If suspect organisms are seen, one must re-culture requiring more time. Then finally a capsular test can be used and may confirm that anthrax is even more likely, but still not certain. And ultimately a DNA test can be done, though that’s not available except, I think, at CDC.”

“But isn’t there a blood test?”

“Yes, but that relies on the presence of antibodies. It requires that actual infection be present for at least a few days, and even so it is not diagnostic; as in the capsular test, other non-anthrax organisms can lead to a positive blood test.”

“Well  shit! It seems to me the news media has been great on sensationalism, the modern standard for professional journalism, and terrible on informing the public!”

” Tell me about it!” I said. “They do best what pays best.  And they are not alone. It is the law of the land,  primum dollarum. Res Upsa Loquitor and al that stuff.   Sorry, Judge!  But maybe, in large part, contradictions result because the best course is truly unclear yet. The solution, or solutions, are complex. We are all learning. A relatively  qualified expert may never have personally seen a case of pulmonic anthrax, and read about less than a hundred in recent years, most all in foreign countries, and some 85 or so downwind from a Russian biological warfare facility in the former USSR. How does one decide, for example, what antibiotic is best? Only the makers of Cipro, an expensive proprietary antibiotic, did the research; it didn’t pay to research the low cost antibiotics. But even then there was no work on real people.”

“ If I were cynical, which I’m not, I’d wonder if Bayer sent the envelopes! Sorry for the bad joke! This has me wierded out. I’ll send her down. Thank you. I really do think doing a test will help.”

So here we are; all waiting for the results of the nasal swabs. Today I spent more time on Browser, and rode him through the National Library of Medicine, at nlm.nih.gov. We galloped through dozens of article summaries, and nothing changed so far as my patient is concerned. I know a little more about vaccines, which, so far, are monumentally impractical for general use. I also spoke with the local health officer, who confirmed that until I had an actual case, or credible evidence of high risk, neither they nor the police would get involved.

“But,” I objected, “if the case is pulmonic, actually mediastinal, the first patient dies.”

“That’s right. Like the index case in Florida. The rest usually live.”

“Cool,” I said dryly. But that’s state of the art, until we learn more. To paraphrase Pogo, “We have met the  unqualified and unprepared Leaders, and they is us.”

Vesicants – a WWI Weapon

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Fifth in a series on  for biochemical terrorism .  (2003)

The purpose of terror is not mass killing but mass panic and chaos.

At 3 a.m. on a summer Sunday, an 18-wheeler rolls down Highway 80 past Roseville, trailing a light orange mist that is almost invisible in the still warm night air. It moves on to Sacramento next to W-X streets, West Sacramento and Davis, where it is abandoned at Sycamore and Russell Streets. At the junction of Highways 5 and 80, a similar rented semi arrives from Stockton, turns right at P Street and continues on a circuitous route to Fair Oaks Boulevard and ends at Folsom.

Between 3 a.m. and 5 a.m., tens of thousands have been exposed to a vaporized vesicant. They note only a garlic-like smell, but little else. During the next 2-24 hours they develop persistent respiratory and eye irritation, and burning of the skin. Alarmed, they find that many others have the same symptoms, and it is obvious that something is very wrong.

They have been exposed to mustard gas, used in WWI. Emergency Department phone lines and waiting rooms are overwhelmed; medical staff are exposed to the same substance, before finding that both immediate decon­tamination of the victim (preferably within minutes, with soap and water or dilute bleach), and protection of hospital staff from secondary exposure, are vital.

Adequate decontamination equipment and protective clothing are not readily available, let alone large amounts of bleach. Some major hospitals are in the exposed zones close to freeways, so their triage and decontamination procedures, preferably done outside, must be moved to an uncontaminated parking lot or school. Pool supply stores and markets are asked  to supply  bleach, but supplies run out quickly. And unless more impermeable gear and gas masks can be found, hospital staff must do the best they can with gloves, surgical masks, face shields and makeshift barriers.

The Health Department quickly finds the micro aerosolized vesicant to be simply sulfur mustard, of the type used in WW I, absorbed immediately but with multiple delayed effects. It becomes clear that the results of decontamination efforts have been minimal. Within 48 hours of expo­sure, symptoms appear, including: Respiratory failure, blisters re­quiring debridement and, later, bone marrow depression. While most hospital staff are not so affected as the original victims, skin lesions and bronchitis are very slow to resolve.

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Gabriel And The Mullah

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He passed down a long tunnel of light, into a bright void. All he could see was a small blue button with some writing under it. In 47 languages, one being his native Arabic, it was written:  If you are Male, ring this bell. If Female cover yourself and wait, unless you are a virgin; in that case, ring the bell continuously, until you feel a pain between your thighs for one second, then cover yourself and wait.

He pressed the button.

“Hello, can I help you?”

“Is this Allah himself, Praised be his name forever?”

“No of course not. This is Gabriel. Even Muhammad, praised be his name, went through me. Have you forgotten your Qur’an?”

“Sorry, I just thought, well, under the circumstances…”

“The circumstances aren’t that unusual. Read some history. What can I do for you?”

“Do I have to tell you? Don’t you know who I am?”

“OK; Of course. I was just trying to make you feel empowered. You seem so anxious.  I know who you were, and all about it.”

“You know who I were; I mean was? You mean I’m dead?”

“I’d say so. And male. That’s why your call got through. Otherwise you’d have got the phone tree. You know: If this, say one; if that say two; to infinity; then, if you last so long, the dial tone. We call that Limbo, just like the phone trees there among the… infidels; I don’t like to say their name. Can you believe the barbarians remember the Prophet Jesus, may he live forever, by eating his flesh and drinking his blood?  Yuq! But they invented some good scams, like hell, and limbo, and selling absolution, even though they were so stupid they killed Him. We use what we can of theirs, if it works.”

“But if I’m dead, where are my virgins?”

“For shame! They are only for young men who die bravely. Cadaverous mullahs who hide in caves don’t qualify, especially when they die like you did. I won’t go over details, so as not to embarrass you.”

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Terrified of Terror

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This report is based on a real episode though details are modified to preserve anonymity. One of a series on bio-chemical terror, 2002.

Oct 17, 2001 – At 5:00 p.m., the secretary to a local judge appeared requesting to be seen for an urgent matter. I knew her to be a very capable, no nonsense person, not given to exaggeration, who had always been in good health. Her problem was one I had thought about, but had never expected to face in my own practice. She had opened a suspicious letter and was concerned about anthrax exposure, because she now had a sore throat and general aching.

“What did the letter look like?”

“It was hand addressed to the ‘County Court.’ I opened it and some gray dust fell out.

Inside was a weird note.”

“Weird? You mean threatening?”

“Well, I’m not really sure. I couldn’t say. It made no sense. It was about ten words, written in block letters. It was so strange I just laughed, and showed it to the law clerk, then threw it out. But it wasn’t exactly funny, and I washed my hands after.

That was four weeks ago; I never gave it a thought ’til now, with the anthrax thing.”

She and the clerk couldn’t recall, even after thinking back as hard as they could, what the note said. There had been no other symptoms, no fever, no other people ill at work, or at home.

“There’s one other thing, doctor. I had some Cipro and started it yesterday. It was the prescription they gave dad before he died. I know I shouldn’t have, but I heard that by the time you get symptoms of pulmonary infection it’s too late.”

I’d planned to play poker that night with the good old boys and some bad old girls, but I sat down, resigned to my fate. At this time of day, the local Health Department was in phone tree answering

machine mode. But with this scenario they wouldn’t have done anything at this point

anyway. Nor would the police. I realized that now I, in my myopic way, was also a victim of terror.

Then I remembered the mythic e.net. I excused myself, went to my office, and mounted Browser, my net-horse, settling easily into my Windows saddle for a pixel ride. I would go until I reached a place where a clear decision tree was laid out. I knew that there was some sort of CDC national plan where local police and health departments were terrorism first-responders. But here there was no longer an obvious crime scene, so I urged Browser on expectantly to What Next.

Read the rest of this entry »