EMT-Basic Exam: The Basics of Operations - Weapons of Mass Destruction

Weapons of mass destruction (WMD) present unique challenges for EMS workers. These threats come from three distinct sources: international terrorists, domestic issue terrorists, and lone terrorists.
EMS crews are often the first people to respond to an incident involving a WMD. The WMDs you may encounter in the field include chemical, biological, and radiological threats. Understanding your role in an incident involving WMDs is critical to protecting yourself and your patients. Although these situations are uncommon in the field, you will encounter questions about WMD incidents on the EMT-Basic exam.

1. Agents of Terrorism
The effects of chemical, biological, and radiological weapons can cause significant damage if the signs and symptoms are not recognized and treated immediately. Because it is often difficult to determine the sources of chemical, biological, and radiological weapons, the best way to identify an agent of terrorism is to become familiar with the common symptoms of exposure to such weapons.

a. Chemical
The most common agents used in chemical attacks are nerve agents, including tabun, sarin, soman, VX, and novichok. These agents produce a toxic condition called cholinergic crisis. EMT-Basics use the acronym SLUDGE to remember the symptoms of cholinergic crisis. SLUDGE stands for
- Salivation
- Lacrimation
- Urinary incontinence
- Defecation incontinence
- Generalized weakness
- Emesis

Nerve agents are especially dangerous because residue can cling to the victim’s clothing, skin, and possessions for days after the initial exposure. Because the risk of contamination is high, EMT-Basics must take the proper BSI precautions before assessing or treating the patient. EMT-Basics should always wear rubber gloves and chemical-resistant clothing with an air filtration system while treating victims of a chemical attack.
Treatment of victims who have been exposed to nerve agents often involves the administration of atropine and pralidoxime autoinjectors. After such drugs are administered, immediate transport to a specialized facility is usually required.

Terrorists also use vesicants, or blister agents, as chemical weapons.

Vesicants, which include mustard and lewisite, have the capability to kill growing cells in bone marrow and the gastrointestinal tract. They also cause blisters within the airway and on the skin. Up to 24 hours may pass between the patient’s initial exposure to the chemical and the onset of painful symptoms. This makes it difficult to discover where and when the patient was infected. If not treated, vesicants can cause immune system failure, which can lead to death. If blisters have formed in the patient’s throat, you must ensure that a patent airway is maintained at all times. This may require you to intubate the patient before transport to the hospital.

Like nerve agents, vesicants leave residue on the patient’s skin and clothes, which can infect EMS workers. The contents of the blisters are not toxic, but EMT-Basics should avoid touching the area unless barrier protection is available.
Chemical asphyxiants (including the gases carbon monoxide, cyanide, and hydrogen sulfide) are another form of chemical warfare commonly employed by terrorists. These chemicals affect the patient’s breathing, which may lead to unconsciousness or death if left untreated. Carbon monoxide is extremely difficult for humans to detect because it is colorless and odorless. Specialized equipment can sometimes assist EMS workers in determining if carbon monoxide gas is present. Cyanide gas, however, sometimes gives off a bitter almond scent. Hydrogen sulfide may produce a smell similar to rotten eggs.

Symptoms of chemical asphyxiant poisoning include headaches, nausea, restlessness, and a decrease in the person’s attention span. Long-term exposure to these chemicals can result in unconsciousness, which can quickly lead to death if the patient doesn’t receive immediate treatment.
EMT-Basics may suspect chemical asphyxiant poisoning if they treat multiple patients with similar symptoms. In most cases, these symptoms are treated by removing the infected patient from the scene of exposure. In cases of cyanide poisoning, EMT-Basics may need to use a cyanide antidote kit under the supervision of medical direction. When responding to an incident that may involve chemical asphyxiants, EMT-Basics must outfit themselves with the proper respiratory protection.
 

Terrorist groups may also utilize lung irritants (such as chlorine, ammonia, and phosgene) in an attack on the population. Lung irritants often produce a strong odor. Once inhaled, they create an irritating sensation in the nose and lungs, which may produce fits of violent coughing.

It’s important to note that these chemicals are also used by various industries across the country. Every day, trucks and trains transport these chemicals to labs, factories, farms, and research facilities. An accident involving these vehicles could release lung irritants into the environment. Once released, these chemicals often form low-hanging clouds that are easily transported by the wind. Fortunately, these clouds help EMS workers establish a safe zone away from the scene of the initial incident. In these cases, you may be responsible for evacuating people from the area. Always take the proper BSI precautions before attempting an evacuation. Never drive your vehicle through one of these low-hanging clouds during an evacuation. Find an alternate route that doesn’t put you at risk of exposure.

Exposure to lung irritants may lead to damaged cells in the lungs, adult respiratory distress syndrome, or the formation of noncardiogenic pulmonary edema. There are no antidotes for lung irritants, so EMT-Basics should remove infected patients from the area and provide them with high-flow oxygen. Further treatment often involves lots of rest. Constant movement and heavy breathing will only spread the irritant throughout the lungs and into other areas of the body.

b. Biological
Terrorists use biological weapons to spread illness and disease throughout a designated area. The most common biological weapons are microbes (bacteria or viruses) and toxins (chemicals derived from microbes). Both are often extremely contagious. If you’re responding to a call that may involve biological weapons, it’s important to wear the appropriate BSI gear. Because many illnesses are airborne, you must protect yourself by wearing gear with either an air filtration system or an independent air supply.

EMS workers are often the first to recognize the spread of a biological illness. After treating multiple patients with the same symptoms over a period of hours or days, EMS workers should report their suspicions of a biological illness to dispatch, local hospitals, or medical direction.
Symptoms of illnesses caused by biological weapons are similar to pneumonia, which can be life threatening to young children and the elderly. As time passes, physicians or scientists may confirm the presence of a bioterrorism agent. 

Common bioterrorism agents include
- Influenza
- Tularemia
- Brucella spp.
- Plague
- T-2 mycotoxin
- Staphylococcus enterotoxin B
- Ricin
- Anthrax

Often, neurological conditions are indicators of bioterrorism. Those infected may experience paralysis, loss of function in their extremities, and numbness. Although neurological conditions may support the presence of bioterrorism, physicians must first rule out more common causes of these symptoms, such as consumption of expired foods or improper handling of raw foods. EMT-Basics who respond to calls where multiple patients are experiencing neurological symptoms may be in the presence of one of the following bioterrorism agents:
- Botulism
- Venoms from snakes
- Venezuelan equine encephalitis
- Maitotoxin
- Ciguatoxin
- Tetrodotoxin

Another rare but serious biological weapon you may encounter as an EMT-Basic is hemorrhagic viral disease. Patients suffering from a hemorrhagic viral disease experience abnormal bleeding and fever. Symptoms of the disease include bleeding from the gums or rectum, vomiting blood, and easy and excessive bruising. Emergency personnel can test for hemorrhagic viral diseases on the scene by fixing a standard venous tourniquet. If small spots appear under the skin or excessive bruising forms near the tourniquet, then the EMT-Basic should call medical direction and the hospital to warn them of a possible case of hemorrhagic viral disease.
Other diseases contracted after exposure to bioterrorist agents include
- Rift Valley fever
- Congo-Crimean hemorrhagic fever
- Ebola virus infection
- Korean hemorrhagic fever
- Smallpox

All of these diseases are extremely dangerous. Be sure to outfit yourself with the proper BSI gear if you suspect that your patient may be suffering from one of these illnesses. Remember that signs and symptoms of infection may take days or weeks to manifest, so it is important to monitor your health carefully if you’ve been exposed to one of these biological agents.
The course of treatment for exposure to bioterrorist microbes, toxins, or diseases will largely depend on which agent the patient has been exposed to and, in some cases, the length of exposure. This is why it is important to try to identify the agent and then contact the closest medical care facility to alert it of the issue before initiating transportation. EMT-Basics should also contact their medical direction physicians for advice on interventions that could help stabilize the patient or provide pain relief.

c. Radiological Devices
Radiological threats differ from biological and chemical threats in that they can be detected and measured using specialized equipment. At any time, a device can be used to test for the level of radiation in a given location. Luckily, the human body is resistant to many forms of low-level radiation as long as these substances are not ingested or inhaled.
This type of terrorism often involves hiding a small piece of radioactive material in a crowded area. People who pass by the material are unknowingly exposed to radiation. Over time, hundreds of thousands of people could be exposed to radiation. Terrorists may also contaminate the food or water supply with radioactive materials.
When responding to a call that could involve a radiological device, EMT-Basics use a Geiger counter to measure the level of radiation in the area. Crews who don’t have access to a Geiger counter may have to obtain one from other emergency response teams. If the Geiger counter indicates that radiation is present, patients are transported to the hospital where they receive a series of tests. If a person has been exposed to enough radiation over an extended period, he or she may develop radiation syndrome, which can cause serious damage to the immune system.
In situations involving radiological devices, EMT-Basics are responsible for decontaminating the patients and transporting them to the hospital.

Decontamination can involve many forms, but the basic principles involve washing off any external contaminants with soap and water. Sand and clays may also be used for liquid contamination. During this process, EMT-Basics should protect themselves from cross-contamination by wearing, goggles, gloves, and gowns. After the decontamination is complete, more testing is often necessary before a course of treatment can be determined for these patients.

A Geiger counter.

2. Response Strategies
Recognizing that an emergency may involve a WMD is both critical and difficult. If you’re responding to an emergency at a highly publicized political or social event, be suspicious of the cause of injuries or illnesses. Other clues that might signal a terrorist attack include a drastic increase in the number of people suffering from a rare illness or a certain section of the population (designated by age, race, sex, or religion) suddenly becoming extremely ill.
If you suspect a terrorist attack, contact medical direction, the hospital, and law enforcement officials before transporting the patient. Once transport is complete, your vehicle and your crew must be decontaminated before responding to another call.

Related Topics You Should Review:
- Treating patients exposed to nerve agents
- Treating patients exposed to chemical asphyxiants
- Using a cyanide antidote kit
- Treating patients exposed to riot control agents
- Managing blast injuries
- Methods of decontamination
- Maintaining infection control