A successful “antidote” program focuses on three principal and closely interrelated factors: (a) supply; (b) training; and (c) security. There are currently many antidote kits that are either commercially available in the industrial community, or in the nation’s chemical weapons arsenals, that can be used to fight the threats posed by accidental or even deliberate spills of hazardous chemicals. However, for various security and “deployment” reasons, those kits can be divided into two groups – those with a significant potential for abuse, and those without.
Although there might be only a slight possibility that medications “without” a significant abuse potential could and/would be diverted by otherwise conscientious staff – “so they can have them available for themselves or their families,” is one plausible reason that has been cited – that would be a relatively limited problem that could usually be reduced, or kept to a minimum, by a rigorous program of frequent inspections, many of them unannounced, and a continuing emphasis on both personal and collective accountability.
Of much greater concern are the medications “with” abuse potential because they must be secured more strenuously than the others, which often translates into additional levels of security – and that means, in turn, that these medications my be less readily available when immediately needed. To consider but one example: A supply of Diazepam (also known as Valium) is and should be an essential component of an effective nerve-agent antidote program. But it is a “Schedule 3” medication with high abuse potential and therefore must be secured – but at the same time be quickly available if the unthinkable happens. If staff members are diverting Diazepam for recreational use, which could seriously impede decision making, the staff members involved must be not onlyentified but also removed from the patient-care arena before any injuries or even deaths can occur.
Frequent Inspections Plus Personal Responsibility One strategy used to create and maintain a secure antidote program in which the medications needed are still accessible is to require paramedics to inspect, and sign for, a quickly measurable supply of the medications available at the start of each shift – as paramedics already do for the Diazepam they carry to treat seizures. That distribution model has two principal advantages: (a) the medication is inspected at least once or more every day; and (b) each succeeding paramedic is personally responsible for checking the medications turned over by the individual paramedic he or she is relieving. There are two additional points that should be kept in mind, though: (1) If the policy adopted is the same as that used for other medications with abuse potential, there will be at least some additional training required; (2) There also is a possibility that the variety and the bulk of the medications signed for may make this model unwieldy.
Another likely model is to have a stockpile of various medicines, including Diazepam, that, although kept under tight security, could be made immediately available for transport to the scene of an emergency. This model allows for tighter security because the day-to-day supply would be kept under the control of a very limited number of people. The “stockpile” model also may be impractical, though – particularly in agencies responsible for operations over a relatively large geographic area – because the transport time from the stockpile cache to the emergency scene might be much greater.
The “average” paramedic unit usually carries enough supplies already, including medicines, to treat some if not all types of chemical poisoning. For example, the recommended treatment for hydrofluoric acid usually includes the use of calcium gluconate or calcium chloride, which currently may be carried by paramedics to treat cardiac problems. However, that antidote does no good if the paramedics – and/or the physicians who support them – are unaware of all of its possible uses. Again, additional training probably would be needed.
Protocols, Procedures, and Other Practical Realities Treatment protocols – i.e., the legal rules and regulations that paramedics must follow when administering medications – must also be specified, in considerable detail, well in advance to not only provide the directions on when and how to use the medications but also to serve as the legal basis for their use. Unfortunately, without sufficient paramedic training related to these treatment protocols, the protocols themselves are useless. Moreover, the medications usually stockpiled to cope with CBRNE (chemical, biological, radiological, nuclear, explosive) attacks or incidents are useless if the responding EMTs and/or other medical staff do not know how to access and administer them.
In short, maintaining security over a supply of antidotes requires much more than simply ensuring that they are not diverted for recreational use. It is at least equally important to protect not only the specific locations of the various caches involved but also the operational details of the supply procedures used.
Thanks to the already validated assumption that there are forces in the world able and willing to use chemical weapons (and/or industrial chemicals) to attack civilian populations, it is not a far stretch of the imagination to recognize that those same forces would also be willing to attack the individual responders – and material resources, including antidotes – that the nation would and must use to counteract such attacks.
Joseph Cahill is the director of medicolegal investigations for the Massachusetts Office of the Chief Medical Examiner. He previously served as exercise and training coordinator for the Massachusetts Department of Public Health and as emergency planner in the Westchester County (N.Y.) Office of Emergency Management. He also served for five years as citywide advanced life support (ALS) coordinator for the FDNY – Bureau of EMS. Before that, he was the department’s Division 6 ALS coordinator, covering the South Bronx and Harlem. He also served on the faculty of the Westchester County Community College’s paramedic program and has been a frequent guest lecturer for the U.S. Secret Service, the FDNY EMS Academy, and Montefiore Hospital.