FEATURED AUTHORS
BARRY MISKIN & MATT BOLINGER

The September 11, 2001, terrorist attacks were a wake-up call for Americans. For most, 9/11 was a clear signal that to rely solely on the government or law enforcement to defend and protect American citizens was to deny reality and leave themselves and their families vulnerable. Many were filled with a firm resolve that demanded accepting a new level of responsibility for protecting themselves, their families, and their country against potential future attacks. Almost overnight, Americans who had always felt safe and secure entrusting their safety and their lives to those in charge recognized that they were partially responsible for their fate and quickly redirected their focus toward awareness, preparedness, self-protection, and survival.

For Paladin, tangible evidence of this shift in focus came in the form of a steady stream of manuscript submissions from authors whose expertise in a variety of fields equipped them with valuable insight on how to prepare for, defend against, and respond to future terrorist attacks. The popularity of such books and videos led Paladin to add a whole new category to our lineup in 2004. The Terrorism category's most recent additions come from two experts in the field of medicine: First-Response Medicine for Terrorist Attacks by Barry M. Miskin, MD (March 2004), and Recognizing and Treating Exposure to Anthrax, Smallpox, Nerve Gas, Radiation, and Other Likely Agents of Terrorist Attack by Matt Bolinger, MD (May 2004).

Highly regarded for his experience and expertise in emergency medicine, Dr. Miskin organized a 2003 conference on the medical care of terrorism victims sponsored by the Palm Beach County Association of Operating Room Nurses and remains active in supporting bioterrorist response organizations. Dr. Miskin holds the title of Fellow of the American College of Surgeons, the highest honor that can be bestowed upon a surgeon.

Epidemiologist Matt Bolinger, MD, has extensive training in symptomatic recognition and tracking of a bioterror agent release and conducts disease outbreak and field investigations for three counties in the southwestern United States. He spends the majority of his time on disease surveillance (with an emphasis on bioterrorism) and analysis of population disease statistics.

Barry Miskin, MD

After training as a surgeon at Rutgers University Medical School, I took my residency at Cooper Hospital/University Medical Center, the busiest hospital in South Jersey. I picked that hospital precisely because of its strategic location in one of the most crime-ridden cities in New Jersey so I could develop and hone my surgical skills on the abundant shooting, stabbing, and beating victims who entered the medical center for treatment on a daily basis.

The South Jersey Shock and Trauma Center, modeled after the field hospitals used during the Vietnam War, was founded during my time at Cooper. All victims of blunt and penetrating trauma from Cape May to Trenton were sent to Cooper's trauma center by helicopter or ground transport. This volume of activity afforded me a great deal of clinical experience in treating victims of all forms of stabbings, shootings, beatings, bombings, falls, electrical burns, explosions, and automobile accidents. On top of this, I also gained experience through chemical agent poisonings that sometimes occurred in the local industry as well as biologic agent illnesses frequently seen in the varied foreign population in the area.

In all of these experiences, I observed some common principles, which I continued to develop in my private practice, through my continued experience with trauma at St. Mary Medical Center Trauma Unit in Florida, and as an advanced trauma life-support instructor with the American College of Surgeons. In the latter role, in which I have served for the past 20 years (first at Rutgers University, then at University of Miami, and now at Nova Southeastern University School of Medicine), I have helped to train multitudes of paramedics and firefighter-paramedics in first-response medicine.

Over the course of my career, I have refined these common concepts culled from my trauma experience into what I call “10-minute medicine”—a simple set of instructions designed to help sustain the life of an injured person for the first 10 minutes after the incident until professional help is available. As a direct result of teaching groups the principles of 10-minute medicine to medical professionals as well as laypeople, individuals outside of the health care profession have put these life-saving measures to the test countless times in order to save lives—their own or those of their friends and family members. By imparting one or two pieces of crucial information, 10-minute medicine enables anyone to rise to the challenge of the most life-threatening situations.

As a resident of Palm Beach County, Florida, where I serve on the faculty of Nova Southeastern University School of Medicine, I was affected personally by the anthrax terrorist attack in Boca Raton in 2001. Convinced that it was not a question of if but when another terrorist attack would occur within our borders, I was determined to prepare for this new threat to our country. I began to educate myself on all forms of terrorism—including biological, chemical, nuclear, and conventional bombing attacks—and first-response medicine for treating the resultant trauma. From the numerous conferences and lectures I attended on these subjects, I took away many messages that compelled me to take action.

First and foremost, I noted that there were many physicians at these meetings who had no clue how to handle the medical situations that arose from terrorism. If the doctors don't know what to do, I wondered, how could anyone else? With this in mind, I realized that the terrorists were accomplishing their prime objective—easily creating panic and fear (i.e., terror) among our population.

Recognizing that the Israeli experience with terrorism was the most comprehensive on the planet, I set out to learn more about the Israelis' tactics for survival. I attended national conferences featuring speakers with intimate knowledge of the Israeli experience and trained with Israeli surgeons, including one who is presently working in a trauma center in Jerusalem, on their treatment tactics for victims of terrorist attacks.

In the course of my quest to become fully informed and prepared, I came to see how simple pieces of crucial information could save lives in the event of a terrorist attack. For example, all chemical agents used by terrorists are heavier than air, which is why the Japanese terrorists used the subway as a staging ground for their insidious sarin attack. By going to higher ground quickly, it is possible to escape death or injury from these agents.

I knew that if a person could survive an injury or exposure for the first 10 minutes and be stabilized enough to get to professional medical assistance, his or her chances of surviving were greatly increased. Yet in reading every book on the market to further my own knowledge, I realized that the available literature was too technical for the average person or family. It was at this point that I decided to write a simple first-aid book geared toward treating victims of NBC agents and conventional bombings.

A small, quick-reference text that could be kept in the first-aid kits, glove compartments, kitchens, and offices of ordinary citizens so that it was readily available if danger arose, the book I envisioned would be filled with charts and illustrations that would make it easy to follow and thus simplify the concept of quick care. To this end I applied the principles of 10-minute medicine that I'd been developing throughout my career. The result is First-Response Medicine for Terrorist Attacks: What to Do in the First 10 Minutes, published by Paladin Press.

Q & A

Paladin: Has the creation of the Department of Homeland Security increased the readiness of the medical community to treat terrorist attacks?
BM: Physicians are presently benefiting from courses in bioterrorism developed primarily by the American Medical Association, College of Emergency Room Physicians, and American College of Surgeons, but the level of readiness is still far from the scale that it needs to be. And there is a real need to increase training for police, paramedics, and firefighters in HAZMAT (Hadardous Materials).

Paladin: What are the most significant things ordinary citizens can do to increase their odds of surviving a terrorist attack?
BM: Always be aware of your environment and consider everything. For example, a simple liquid oxygen tank can be turned into a bomb. Household chemicals and items such as chlorine for pools or bug spray can be turned into chemical weapons. Notice anything suspicious and have basic items available within easy access, such as water to decontaminate, plastic bags for contaminated items and for protection, a cell phone to call for help and alert authorities, and of course, my book. It includes a list of many other simple, everyday items to keep on hand and gives information on how to help someone within the first 10 minutes of their suffering an injury or exposure.

Paladin: During a medical emergency, what should the first-responder do first?
BM: Don't become the victim yourself. Stay upwind of chemical agents and stay on high ground. Chemical agents are heavier than air. Protect yourself from any suspected biological agents or dirty bombs. Beware of contaminating yourself through exposure to blood, as hepatitis, AIDS, and other diseases can be transmitted this way. Assess the situation and remember the ABCs: airway, breathing, and circulation. Address the problems that will kill your victim. People can only survive so long without oxygen and circulating blood. After about four minutes, brain cells start dying. After losing a liter of blood, people start to go into shock.

Paladin: What type of things do you recommend having in a home first-aid kit?
BM: A basic supply includes bandages, tape, water, Betadine, rubber gloves, rope, splints, plastic bags, and duct tape, to name a few. A comprehensive list can be found in my book.

Paladin: If you are away from your home, office, or automobile first-aid kit and have no medical equipment with you, what are some common items that can be used in a pinch to treat someone?
BM: The possibilities are limited only by your own imagination but might include, for instance, a shirt, ripped up to make dressings, baggies filled with water to irrigate wounds, rolled newspapers to form splints, bourbon or vodka to cleanse wounds, and Kotex to serve as an absorptive dressing.

Matt Bolinger, MD 

My interest in chemical and biological weapons began at the tender age of 12, when I spent many hours in the garage attempting to create anything that would produce smoke, fumes, or sparks. The clandestine operation continued for months, fueled by technical advice from a very imaginative cousin (let's call him “Fred”). My experimentation came to a crashing halt when my father discovered my passions: he caught me mixing pool chlorine tablets with muriatic (hydrochloric) acid in a dog food can. This, of course, was when corporal punishment was an accepted form of correction. The ordeal—and subsequent spanking—did curb my enthusiasm for hands-on experimentation. Short of a few mischievous events with Fred, my study of the subject became exclusively academic.

My father's explanation of the dangers involved in the chlorine/acid reaction persuaded me to spend months reading about the history and application of chemical and biological weapons. But my enthusiasm for the subject diminished as I discovered sports and the opposite sex. The flame might have been extinguished altogether had it not been for an interesting lecture that I attended during my second year of medical school. The lecture was on organophosphate poisoning and included a mention of nerve gas. (My intense questioning of the professor during the lecture garnered many strange looks from colleagues and fellow students.)

In that hour, I discovered a whole new way to look at chemical and biological agents and was infused with a renewed vigor to study, which eventually led me to base my clinical thesis on the need for physician training in recognizing and treating warfare agent toxicities. (My book Recognizing and Treating Exposure to Anthrax, Smallpox, Nerve Gas, Radiation, and Other Likely Agents of Terrorist Attack [Paladin Press, May 2004] was derived from that thesis). I knew that I had found my calling, and this study would eventually steer me on my path toward a career.

The medical aspects of the agents fascinated me. This fascination, fueled by multiple viewings of the movie Outbreak, ultimately inspired me to enter the field of epidemiology. As an epidemiologist, I conduct disease outbreak and field investigations for three counties in the American Southwest. Most of my time at work is spent on disease surveillance—looking for possible signs of biological terrorism or other agent release.

Today, even after the anthrax attacks of 2001, there continues to be a great need for training in the United States on recognizing and treating chemical, biological, and radiological toxicities. Physicians and citizens alike should arm themselves with a basic understanding of how to recognize and treat exposure to anthrax, smallpox, nerve gas, radiation, and other likely agents of terrorist attack. I hope that my passion for the subject, which led me to write Recognizing and Treating Exposure to Agents of Terrorist Attack, can better educate Americans about likely agents of NBC attack.

Q & A

Paladin: Are most hospitals and emergency rooms prepared to treat victims of NBC warfare?
MB: At present, hospitals are preparing to treat mass casualty groups. Hospitals and ERs have received funding from the federal government to increase their capacity to respond to such incidents. Even though there is much work to be done, I feel like good progress is being made.

Paladin: Are many doctors trained in recognizing the symptoms?
MB: Great efforts are being made toward this goal. Health care providers are now being trained in recognizing and treating warfare agent toxicities. The federal government, hospitals, and local health agencies have all begun sponsoring training events on this subject. In spite of such training, there's the potential that a victim's diagnosis would not come until long after the onset of symptoms, which would lead to great problems if the agent is biological and communicable.

Paladin: Does every county have someone trained to do what you do?
MB: Every state has epidemiologists. I believe that there is a push right now for all local health agencies to procure epidemiological services. But at this point every county does not have an epidemiologist.

Paladin: Has the creation of the Department of Homeland Security (DHS) increased the readiness of the medical community to treat NBC attacks?
MB: I believe that it has. The DHS has been working well with hospitals on increasing their ability to respond to such situations. It has been providing funding to expand mass decontamination capacities and lending guidance on creating and maintaining current disaster plans for health-care facilities. It has also spearheaded many drills and exercises to test these plans.

Paladin: What is the most likely scenario for an NBC attack?
MB: Anything is possible. I believe our water supply is a vulnerability issue. Groups sending infected individuals across our borders could turn out to be a problem. There are extremists who are willing to strap a bomb onto their chest and walk into a crowded room before detonating it. Would such a person, who is willing to commit suicide, have a problem with being voluntarily infected with an agent (smallpox, plague, Ebola) and crossing through Customs while still in the incubation period? I see this as a major possibility. The ensuing panic by the uninformed masses could potentially cripple our great nation.

Paladin: Do you recommend vaccinations for such diseases as smallpox for ordinary citizens? Are they worth the risks?
MB: At the present time, vaccinations for smallpox have slowed to a halt. There hasn't been a known case of smallpox for years, and the smallpox virus is thought to be eradicated from the planet. Some of the virus was retained in a few laboratories for "research" purposes. There is a concern that belligerents might use such a virus as a weapon, which would probably shut us all down for a while as authorities worked to contain it. The vaccine for this virus is thought to be safe for most citizens without other medical concerns and seems to show a negligible risk. I would probably have my wife and children receive the vaccination if it were offered to the general public.

Paladin: What should the government (federal, state, local) be doing to better prepare the nation for NBC attacks?
MB: I believe the public should be better informed about the possibilities on the horizon and the things they can do to protect themselves. The DHS is attempting to work toward this. Common citizens are the ultimate target of the terrorist. A better-prepared public should be the goal.

Paladin: What is your reaction to the recent uncovering of an al-Qaida cell's planned chemical attack in Jordan ?
MB: I am not surprised by the news of chemical attack plans in the Middle East. I am surprised that it hasn't happened before now. There are many groups that have a burning hate for us and our friends. These groups will not rest until they are either dead or have inflicted great suffering upon us. We should prepare for this type of thing here in our homeland.

Paladin: Based on that report, what do you think is the likelihood that similar plots are underway within the United States ?
MB: I think it is extremely likely. It is not a matter of if; it is a matter of when.

Paladin: Are we in the United States prepared for an attack in which the combination of chemicals used is such that no single antidote would be sufficient?
MB: Most chemical agents have unique mechanisms of action and unique methods of treatment. Each agent requires its own antidote for the survival of the victim. In the event of a chemical warfare agent release, I suspect that any supply of antidote would quickly be exhausted. Because toxicities of this nature are so rare, antidotes are not widely understood and the reserves are limited.

FIRST-RESPONSE MEDICINE FOR TERRORIST ATTACKS
What to Do in the First 10 Minutes

RECOGNIZING AND TREATING EXPOSURE TO ANTHRAX, SMALLPOX, NERVE GAS, RADIATION, AND OTHER LIKELY AGENTS OF TERRORIST ATTACK