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ACMT Chemical Agents of Opportunity for Terrorism: TICs/TIMs

Charles McKay MD, FACMT American College of Medical Toxicology Bethesda, MD, April 29, 2014

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What is Medical Toxicology? •  A medical subspecialty focused on the diagnosis,

management and prevention of adverse health effects from medications, occupational & environmental toxins, and biological agents

SOLVENTS

PESTICIDES

HEAVY METALS

WORKER SAFETY & FITNESS FOR DUTY

ENVENOMATIONS

DRUG OVERDOSE

BACK PAIN

REPETITIVE STRAIN INJURIES Occupational

Medicine

Medical Toxicology

Acute and Critical Care Medicine

TERRORISM (Bio/Chem/Rad)

Infectious Disease

ACUTE ORGAN FAILURE SYNDROMES

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Medical Toxicology •  Officially recognized as a subspecialty

by the American Board of Medical Specialties

•  Of ~800,000 physicians in the USA, less than 700 ever board certified in medical toxicology

•  ~600 physician members of ACMT board certified in medical toxicology

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Examples of Medical Problems Addressed by Medical Toxicologists •  Unintentional and Intentional Drug

Overdose –  therapeutic drugs; drugs of abuse; over-

the-counter medicines; vitamins •  Envenomations

–  snake bites, spider bites, scorpion stings •  Ingestion of Food-Borne Toxins

–  Botulism, marine toxins (e.g. paralytic shellfish toxin, ciguatoxin)

•  Ingestion of Toxic Plants / Mushrooms

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Examples of Medical Problems Addressed by Medical Toxicologists (2)

•  Drug abuse management –  in-patient care for acute withdrawal from addictive

drugs and outpatient Medical Review Officer services for industry and organization

•  Hazardous Exposure to Chemical Products –  Pesticides, heavy metals (e.g. lead, arsenic,

mercury), household products (e.g. cleaning agents), toxic gases (e.g. carbon monoxide, hydrogen sulfide, hydrogen cyanide), toxic alcohols (e.g. methanol, ethylene glycol), and other industrial and environmental agents

•  Independent Medical Examinations –  assessing injury or disability resulting from toxic

exposures

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Medical Toxicologists Provide Professional Services in Clinical, Industrial, Educational, and Public Health Settings:"

•  Emergency departments, ICU's, other in-patient units •  Outpatient clinics, offices, job sites •  Poison Control Centers •  Medical Schools, universities, and clinical training sites •  Industries and corporations (e.g. chemical,

pharmaceutical) •  Governmental agencies (ATSDR, CDC, FDA, DHS) •  Clinical and forensic laboratories

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American College of Medical Toxicology

•  ACMT is a professional, nonprofit association of physicians with recognized expertise in medical toxicology.

•  The ACMT is dedicated to advancing the science and practice of medical toxicology.

•  About 600 board certified or board eligible physicians

www.acmt.net

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Subspecialty training programs •  30 fellowship programs across the US •  2 years in length, average 2 fellows/year •  Generally affiliated with Poison Centers

and academic medical centers •  Serve as educational sites for many

emergency medicine residents in the US –  Other rotating trainees include: Pediatrics,

critical care, medical students, pharmacy students, Pediatric emergency medicine fellows

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United States Regional Poison Control Centers Alaska

Hawaii

Puerto Rico

Guam

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Medical Toxicology Training Programs

ACMT/ATSDR Regional Network: ACMT Regional Directors

Lewis Nelson, MD Fellowship Director Medical Toxicology NYU Medical School Regional Director for Region 2

Fellowships New York, NY

Medical Toxicology University of Regional Director for Region 1

Fellowships Boston, MA Hartford, CT

Worcester, MA

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Tom Martin, MD University of Washington Seattle, WA Regional Director for Region 10

Fellowships

Jennifer Lowry, MD

Fellowship Director Medical Toxicology NYU Medical School Regional Director for Region 2

Fellowships New York, NY Long Island, NY

Charles McKay, MD, Fellowship Director Medical Toxicology University of Connecticut Regional Director for Region 1 and Network Director

Fellowships Boston, MA Hartford, CT

Worcester, MA

Mark Mycyk, MD Northwestern University School of Medicine, Chicago Regional Director for Region 5

Fellowships Chicago, IL Detroit, MI

Indianapolis, IN Cincinnati, OH

Regional Director for Region 5

Fellowships Chicago, IL Detroit, MI

Indianapolis, IN Cincinnati, OH

University of Colorado Denver, CO

Region 8 Fellowships

Andrew Monte MD

Regional Director for Denver, CO

Anthony Pizon, MD University of Pittsburgh Regional Director for Region 3

Fellowships Philadelphia, PA

Hershey, PA Charlottesville, VA

University of California San Francisco, CA

Fellowships San Francisco, CA

San Diego, CA Sacramento, CA

Phoenix, AZ

Timur Durrani MD Regional Director for Region 9

Fellowships San Francisco, CA

San Diego, CA Sacramento, CA

Phoenix, AZ

Carolinas Medical Center Charlotte, NC

Fellowships Atlanta, GA

Nashville, TN Charlotte, NC

Michael Beulher, MD Regional Director for Region 4

Fellowships Atlanta, GA

Nashville, TN Charlotte, NC

Kapil Sharma MD University of Texas Southwestern Dallas, TX Regional Director for Region 6

Fellowships Dallas, TX

Tom Martin, MD University of Washington Seattle, WA Regional Director for

Fellowships Portland, OR

Children’s Mercy Hospitals and Clinics, Kansas City Regional Director for Region 7

Paul Wax, MD Executive Director ACMT

Michael Kosnett, MD ACMT Coordinator for ACMT/ATSDR Cooperative Agreement

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ACMT CONTACTS National (and Region 1):

Charles McKay cmckay@harthosp.org (860) 545-5411 Region 2: Lewis Nelson lewis.nelson@nyumc.org (212) 447-8150 Region 3: Anthony Pizon pizonaf@upmc.edu (412) 647-9922 Region 4: Michael Beuhler Michael.Beuhler@carolinashealthcare.org (704) 512-3750 Region 5: Mark Mycyk mmycyk@cookcountyhhs.org (312) 864-1958 Region 6: Kapil Sharma Kapil.Sharma@UTSouthwestern.edu Region 7: Jennifer Lowry Jlowry@cmh.edu (913) 588-7109 Region 8: Andrew Monte andrew.monte@ucdenver.edu (303) 733-2780 Region 9: Timur Durrani timur.durrani@ucsf.edu (415) 643-3204 Region 10: Tom Martin tgm@u.washington.edu (206) 598-4219 ACMT/ATSDR Cooperative Agreement Coordinator:

Michael Kosnett Michael.Kosnett@ucdenver.edu (303) 571-5778 ACMT Executive Director:

Paul Wax paul.wax@acmt.net (602) 881-5966

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Basic Toxicology Principles

•  Poisoning is an interaction between a host, the environment, and a toxin or toxicant

•  An exposure pathway must be completed in order to have toxicity

•  Exposure to a given compound generally results in predictable, often fairly specific host responses (toxidromes)

•  Dose determines effect – Large scale exposures require large doses – Mere detection of a compound does not identify

it as the culprit

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Basic Toxicology Principles (2) •  It is often difficult to distinguish between

toxicity and host physiological responses – Causation vs. Association

•  General vs. Specific Causation •  The proper care of large numbers of

poisoned patients correctly balances the potential role (including benefit and risk) of – Decontamination – Supportive care – Diagnostic studies – Antidote therapy

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Chemical Agents of Opportunity Course

•  More than 90 courses presented in last 10 years throughout the country

•  More than 9000 participants •  Contributions by more than

100 medical toxicologists

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Agents of Opportunity Topics •  Intro/Background •  Neurotoxins •  Toxic Gases •  Cyanide & Fumigants •  Delivery of Agents by

Food/Water/Drug Supply •  Delayed Toxic

Syndromes •  Radiation •  Psychological Aspects

•  Agricultural Chemicals •  Break-out Sessions

–  PAPRs –  High-Fidelity Simulations –  Radiological survey

instruments –  Tabletop exercise

•  Environmental Monitoring •  Post-Event Biomonitoring •  OSHA First Receiver

Guidance •  Regulatory Aspects and

Local Implementation

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10.

2.3.4.5.6.7.8.9. Basic Science

Administrative or LogisticsVeterinary PracticeOccupational or EnvironmentalPublic HealthClinical Medicine or Nursing (Military)Law Enforcement (Police, MPs, FBI)

Which of the following best describes the type of work you do?

Other

Clinical Medicine or Nursing (Civilian)First Responder (FIre, EMT, Paramedic)

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2.

3.

4.

5.

6.

7.

8. Other

Consulting firm

Corporation

Hospital / Medical Facility

Educationall (university, high school)

Local Gov. (inc police, fire, EMS)

Which of the following best describes who you work for?

Federal Gov. (inc military)

State Gov.