Medical Management of Chemical and Biological Casualties – Vesicants

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We’re talking about vesicles here this morning and by the way, I’m a dermatologist vesicant, our agents that blister the skin that’s just a fancy name for blistering agents. This is for a med centre in school and to keep everything up and aboveboard. You will know for this, these agents at the end. Most of this, no one knows all of this, because all the answers – aren’t in on all of this – I’d, like to tell you right up front that you know how involved the treatment of nerve agents. Aren’t anything. I want you to relax because you already know almost everything about rendering the care to mustard casualty because there is no magic bullet for mustard. It’s all supportive. It’s all the good medical practice that you already know. Okay, so all you gotta do is listen, learn the specific things here and you already know how to take care of mustard casualties. Mustard, sulfur mustard is the biggie. I’m going to spend probably ninety per cent of the time this morning talking sulfur mustard and when I get done, you’ll understand why and also why this old old agent is still one of the top two concerns on a modern chemical battlefield, nitrogen mustard, while Very similar has some significant differences and never has been to my knowledge, really weaponized. Some of its forms are solids, some of its forms, explosives. Some of those forms will eat through the shell, so it’s never been really used to my knowledge as a chemical warfare agent, I would tell you as a dermatologist. I have used it in modern days on patients as a topical medicine for a given lymphoma, called mycosis fungoides and still used to this day. It was our first chemotherapeutic agent back in the 1930s.

Nitrogen mustard Lewis site is very similar to mustard with some significant differences, and I’ll teach you about those. The name Lewis site comes from Captain Lewis, a US captain Lewis, who invented this stuff back in the world war. One time frame, it’s. My greatest aspiration have a chemical warfare agent named after me, just kidding, phosgene oxime is made from phosgene. We don’t have another one with thighs gene and a name just to confuse you. I figured they did that when I took this course, but it’s made from phosgene. Hence the name Fozzie Knox lean and I’ll spend just a little bit of time, in the end, telling you about it. That because it is important for one or two very specific reasons sulfur mustard, first synthesized back in 1822 and then they kind of. Forgot about it and then it was rediscovered and in the mid-1800s way back in the 1800s. Its first battlefield use was in your pre-Belgium, 1917 July right, the last year of the war.

Ok, this is a breakdown of the casualties of World War, one there were roughly a million chemical casualties in a world war, one thirty per cent of all casualties in a world war, one where chemical casualties, but I show you this slide for a very specific reason. You’ve already been told and in World War, one less than five per cent of the casualties were fatal. Okay, and this is the breakdown. Now, if you look at the top three, they were under five per cent. You look at the US and we were at two per cent. You look at Russia, they were almost twelve per cent. We came into the war late. We had the benefit of lessons learned. We also had the benefit of some of our allies equipment. Our first masks were not up to snuff, so we borrowed French mask initially, who had more experience because they’d been in it since nineteen fourteen. So we were better prepared and better equipped the cause of lesson learned and the cause of better preparation and better equipment.

Our fatality rate was half of the rest of them. Russia. By comparison, you remember those masks at dr Seidel showed it looked like something that your grade school would go in and cut out with cardboard. You may lose really funny look what they’re all funny looking, but the really goofy ones that that was their masks early on the Russians had little or no protection. At times their equipment was inferior, their training was inferior and had a 12 per cent with tau D rate. I recently added this one in because I’m trying to make a point about education and training, what a difference it makes and preparation. These are the Kurds. Saddam Hussein gassed about five thousand innocent people that were totally unprotected and it wasn’t a hundred per cent mortality rate, but it was close to it.

So what a difference? Protection education and training make dr Seidel deliberately preempted me with this slide yesterday, but a reminder that, even though mustard came into the war the last year of the entire war, it accounted for seventy per cent of all the chemical casualties and it’s already been made Appointment made that the lethality is low, it’s less than five per cent, but it causes long convalescence. It really screws up the medical scenario as a dermatologist. We very often look, but we don’t see how many will say. You’ve looked right at something. It was right there, plans and those on your face and you didn’t see it in times past. I have been guilty of going around the house looking for my glasses and I had them on. I remember my grandfather bless his soul on occasion would go around the house looking for his pipe and you know where his pipe was so how many people have done dumb things like that? I hope most of you. I hope I’m not unique. Okay – and you know that most of these tell you and show you the percentages of the eye injuries, but you know most of these had worth in the seventy. Five per cent category had a mild injury that self-healed in two weeks, but they were still taken out of action.

They were a problem for the fighting effort. Ok, we heard that, even though there was no actual battlefield usage of chemical agents in World War, two there was the berry harbour accident and I don’t think I heard dr Seidel actually mentioned. There were 600 US casualties and a little over 80 fatalities in that accident. We have no idea how many civilian casualties and fatalities after World War One. You know there have been chemical battlefield uses. We know that I am is used mustard against the Ethiopians. We think we’re almost certain to the Japanese use Lewis side against the Chinese leading up to World War. Two. We certainly know the Rockies used against the Iranians and the Kurds, and it’s alleged that Egypt, usually in Yemen, now mustard, has lots of names and symbols. Most of them have h in it. Okay, so any time in this course, you see H. It stands for mustard, not Hearst. Okay, I don’t want anybody going around saying her site or site or whatever yeah. Here’s, one called HL and it’s a mustard lewisite mixture. There’s a very specific reason for that. I’m going to tell you about that. A little later, these by the way were called Levin’s tubes. They were like a poor man,’s mortar, and it was one way they shot chemicals out of them in a world war. One, you saw gas tanks. Yesterday, you see this structure. This is mustard.

Most of these chemical agents have a very simple structure in summer. As simple as water like Fozzie, you know it’s a very small molecule and the only ones are complicated, more so or the nerve agent ones. This substance down here is thio died. Glycol you see, the only difference is between thio died, glycol and mustard are the chlorines on the end. Wealth I’ll die. Glycol is one of the major urinary metabolites when it’s gone through a person or an animal. It also is the number one precursor to making mustard in the most simple process of manufacturing, and I know if you have filed a glycol which, by the way, is a commercial product using making printers ink and any number of things all you got. Ta do is take thyroid, life calls, throw HCL into it, hydrochloric, acid and voila. It makes sulfur mustard a one-step process. If you have thought I glycol and hydrochloric acid, you could make it in your bathtub. If you were stupid enough well, there are people who are stupid. Enough. Take my word for it not me, guess who was buying up all the thought I glycol he could lay his hands on Saddam guess where he was buying it from one of the places. Germany guesses where else he was buying it from us now guess what the closest city was one of the closest cities he was buying it from Baltimore, guess whoo, where there are some got people from her serving time.

Now: okay, they were using intermediate Ares. They weren’t buying it directly. I don’t think, but they still were breaking along. Mustard is an oily thick substance and at times I have seen it in bulk containers. It looks just like dirty motor oil. It looks like my motor oil whenever I change it: grungy dirty motor oil heavier than air, heavier and water because it’s oily. It has low volatility and it’s quite persistent. Now, here’s a ringer look at the temperature, depending on the manufacturing process, mustard freezes around 57 58 degrees Fahrenheit. When I was in the Gulf War and the ground war kicked off, the temperatures were below that even in the daytime. So Saddam Hussein had thrown pure mustard at us. They’ve been little ice cubes lying on the. We could have laughed that. So this is a significant factor, but there are ways around that there’s more than one way around it, but I’m going to tell you the biggest way around it shortly. The m8 test paper. Okay, turns three colours. You can’t read the writing, but the G agents, turn kind of orange, ish, yellow, H, turns red and the agents turn a dark colour black dark, green-brown. You need to know that the m9 tape is all or nothing. It turns red if it’s, exposed to nerve agents or vesicles the m25 6 kit, which, by the way, is quite good it just it’s and it detects vapours for these detect liquids.

It’s quite good, but it takes about 20 minutes to go through it. It detects the vest, conceit, detects cyanide and detects the nerve agents. The vapours. You need to know that the cam down here is nerve agents, invest against mustard. It also will pick up lewisite, but it will read it out as mustard. Okay, repeat that, I can repeat that twice. If I had, you know what I’m going to review you again and I’ll repeat it: it’s in your little handbook. You really want me to go through that again. Well, I asked for questions. Then this is representative of the m9 paper and it turns three different colours. Okay, and you need to go back and look in the little book. You should try and commit this to memory on the fly put the m8, yeah it’ll turn orange-ish, yellow or something for the g agents. It’ll turn red for the vest concerns a very dark colour for the V agents, the m9 tape. You know, which is what people have on their arms and their legs, so you can only couch turning colours. I better do something: it’s all or nothing phenomena. It turns red if you’ve been exposed to liquid. These are for liquids.

The m25 6 kit is for vapours, it’s a little kit. You got to fold this out and strike this and that it takes and you’ll get it do this in the TX. It takes about 20 minutes, but it detects vesicant, cyanide and nerve agents. Okay, vapours, the cam, you’ll see you’ll get a handle this and look at it. You won’t be made proficient with it in this course. But if you text nerve agents and vest guns and remember on the modern battlefield, the biggies – you’re, going to hear your hair by on the whole ball of wax in this course. But the biggies we’re concerned about on the modern battlefield or nerve agents and vest guns and primarily sulfur mustard, okay mustard when it gets on epithelial surfaces like the skin. It takes about two minutes, for it starts doing its damage. So if you can decon it, if you know you got it on you and you decon it within two minutes or less you, ‘re going to get off scot-free, okay, the problem with mustard is it doesn’t hurt your anything. It can feel just like you got a little water on you or something so it’s a sneaky Pete. It has a late, in effect that I’m going to tell you about eighty per cent of the liquid that gets on the skin evaporates. It goes into the air doesn’t even damage it’s, only the remaining twenty per cent that does its harm. Now they argue about how much does the local damage, but sometimes as little as ten per cent of that remaining eighty per cent. Does the damage on the skin the rest of it gets absorbed and goes systemic you don’t have to root. This is what you need to know.

You got two minutes to get it off of you before it starts harming you. Yet the molecule I showed you of mustard is not the active mooch molecule when mustard comes into contact with water, it’s Ike liza’s into a closed little intermediary. That’s, the one that does the real damage and it acts like greased lightning. Once it goes into that circular ion mustard and I haven’t said it yet is an alkylating agent, just like nitrogen mustard, just like site talks and some of the other things that alkylating agents do. Are they take carbon bonds and rearrange them? So you can imagine that if the carbon-carbon bonds and your DNA have been rearranged, it’s not too healthy. Likewise, it can affect the bonding and the carbon-carbon bonds and your cell proteins, your membranes mustard attacks just about everything it comes in contact with, but we know from studies that your cell proteins, and especially the DNA and acting actively dividing cells, are the most Sensitive targets for mustard, and that tells us a lot about the mechanism of action of mustard.

Thus, when your DNA in your cells has been rearranged on your epithelial surfaces, it can lead to cell death or mutation of the cells vapour by and large, a mustard or liquid is an epithelial phenomenon. The number one sensitive area is the surface of the eye. The cornea followed by the Airways that tracheal the bronchial epithelium and the skin, but if you look at the starting points, they’re not that far apart, okay, but your eye is the most sense to fall by the airways and then the skin down. Here is what it takes to kill you. You learned about LD 50 s and CT the 50s. Yesterday, right everybody got that concept straight. Let me give you a hypothetical situation. I think you also learned yesterday that mustard is actually twice as toxic twice as poisonous per weight. As cyanide, which is a very dramatic agent, because it reacts so rapidly if you took a meter cubed or if you took this room – and you had a big enough puddle of mustard in here liquid and allowed it to equilibrate, so that the room had vapour saturation, depending on what studies you read, is around 600 milligrams.

So you stick. Your head in a meter cube closed area with enough liquid to come to the equilibration that’s the rate, and it only takes how long if that vapour has 600 milligrams in it. For you to get breathe in an ld50 unprotected by mask, takes less than three minutes for you: breath in a poisonous lethal amount of mustard in a totally saturated atmosphere. If you have no protection for the skin by comparison, if you are wearing a mask and you were totally naked and the vapour was hitting the skin, it takes ten thousand milligrams for mustard vapour to kill you through the skin. These are all things, so you know you have comparisons to trying and grasp somewhat intangible concepts liquid, by comparison, you’ve seen some pictures of mustard. Alright, I’m going to show you more but to raise just an insignificant little blister, like a poison, ivy blister you know similar. It only takes 10 micrograms of liquid mustard. Let me remind you that a microgram is a thousand-milligram milligram. Are pretty small to me already, but only 10 000 of a milligram of liquid mustard can at least raise a poison ivy type blister on the skin. An ld50 of liquid mustard on the skin is around seven grams in your classics. Welt. 70. Kilogram mail.

You know something like me: well, he knows I’m lying. I want these cameras when you edit this. I want you to take 20 pounds off of me. You got that so anyway, seven grams of mustard is a liquid ld50. Now teaspoon is like five CCS. You know a gram is equal roughly to cc, so a teaspoon to his teaspoon and a half of mustard is an ld50 okay. As a dermatologist. I would tell you that if you had suntan lotion or oil and you took a teaspoon, teaspoon and a half, you could cover one whole arm and your shoulder front and back and that’s about twenty per cent of your body surface area. So if a patient comes in with fifty per cent liquid burns by mustard fifty per cent, how many LD 50 s? Have they gotten your right? You guys are sharp in some classes. You asked me to scratch your head and everything it’s. It’s 20. In the 50, I just told you twenty per cent – they’ve got two and a half LD 50 s. How do you triage a person with fifty per cent liquid mustard body burns? You got it if somebody comes in with ninety per cent of their body burned and I’m going to show you a picture of it. I hold my breath when I do later on. If somebody comes in with darn near-ninety per cent body burns, how many LD 50 s, are they almost gotten?

They’ve got four and a half close to five LD 50 s. They’re going to be trios expectant. Likewise now I’ve told you that mustards primary targets are epithelial cells and that’s because those are rapidly dividing cells. They have the most sensitive DNA as eyes airwaves of skin, but it does go systemic. Sometimes, if you get enough of it, where it goes systemic all the time, but it depends on how much have you got whether you have a systemic effect? But where do you have rapidly dividing cells internally, the bone marrow, the GI tract CNS is not rapidly dividing, but we’ll talk about CNS later on and a quart and lymphoid tissue. But the systemic effects that you’re going to see most readily are going to be bone marrow and GI. If you get them hand blisters. This is a moderate to severe conjunctivitis with mustard. I’ll show you larger pictures of this later on. These are bronchi. This is supposed to be smooth and round. You look in here. It’s. Gunked up see the pseudo membranes. This is lung tissue, that’s messed up. This is a larynx tongue. I think you might have seen how if you’ve seen this one yet or not, but this is a crispy critter lyric. This is what I, what a non-survivable dose of mustard in the pulmonary tract will do to you. It’s just fried okay. This probably doesn’t, show quite as well with the lighting, but this is a trachea and these are the bronchi. You see the ratty chunks here. You see it should be smooth contour, like a nice, Piper’s, big chunk here how ratty it is.

This is looking down with a bronchoscope. This is down the trachea, and these are the two bronchi. Well, you can barely see any opening, they’re plugged up with the pseudomembranes and world one. Some soldiers died from the mechanical obstruction of the sloughing of the epithelium that’s. What the pseudomembranes are? It’s a physical-mechanical obstruction. You could take a bronchoscope in these days and go down and suck that out. If you had those capabilities. This is another, you know you see how it’s plugged up. I showed you that smaller before now, this is a slide, a show to make a point, depending on which what you read the eyes, the lungs and the skin. They all come in close to 85. 90. 75. It’s all about the same to me. They all got affected in the burn when you got burned, and so we expect the eyes we expect lungs and the skin also comes in seventy-five. Eighty per cent, but look what the top area was. It got burned and the men are already complaining up here.

This goes to show. Men are dumber than when I mean they look down here the hands and feet you, ‘d, almost expect it to be reversed. Wouldn’t yet, okay. Why do you think this is? Were they all sitting around in puddles of mustard and their shorts, or what collected in trenches? What kind of MOPP suits do they have in World War? One none of them had uniforms, they had masks, but mostly they were just wearing uniforms in world war. One now, as a dermatologist, I would tell you that delicate sensitive skin is most susceptible to medicines, drugs or toxic agents. Warm moist skin is most susceptible more susceptible and also included skin okay.

So where do you have delicate skin that’s occluded warm and moist, and then with vapour mustard, going right through the uniforms and then kind of being held? There was a real set up for getting the growing burns. Okay, I’ve told you they got that it interacts and one to two minutes. You decon it in two minutes or less. You’re going to get off scot-free. They used to do this down it in Alabama Aniston at the Kim school, the non-medical course in the old days. When I would have been a young fella, they used to put a drop of mustard a dilute drop on each forearm. They would allow them to deke on one side in two minutes or less and they didn’t get a deke on the other side, guess which side always got the blister and a teensy little scar and which side never got anything well decide to decon clean. As whistle side I didn’t decon got the blister Buster’s onset of effects. You know it’s a latent period. It’s been called radio mimetic it’s. Just like radiation effects. It’s, like some other chemotherapeutic agents. It’s like ultraviolet light from the Sun.

You don’t know you don’t feel anything you don’t know you’re being harmed at first because of its delayed effects, so the onset is usually delayed anywhere from two hours to two days. The average is about four to eight hours. Now, this probably isn’t projecting well, but his chest is a little red mustard starts out and the erythema the redness shows up. First then, it progresses the small little vesicles, which is a dermatological term for small blisters, vesicles or small blisters, and if you got enough of them, they will go on to coalesce to form big, blisters or bully, which is another dermatological big blisters. There is the possibility of liquid mustard. If you get a large amount of anyone it doesn’t get decon, you can skip all this. You can go straight to a third-degree burn what a blacks car. It has happened. Okay, this is the famous person you might have heard about yesterday, who was working at a Depot site, a little eyelet on the back of his boot. Let mustard drip in and I think they say that they calculated that was about a 20-milligram dosage of mustard. Have made this blister?

I have seen blisters that probably looked about like this that were caused by as little as the 10 microgram dosage, but again two minutes to get it off of you two hours to two days to the onset. Obviously, if it takes two days for the symptoms to show up, you, ‘ve got a pussycat of an injury versus two hours, you’re in trouble. Okay, especially if it’s a large area, average four to eight hours, just to blow up of a blistered hand, with mustard that you’ve, seen the smaller picture earlier little bitty blisters all over a couple, big bow. I have formed from the coalescence, by the way, there is no blister. There is no mustard in these blisters hospital personnel. Medics are absolutely not going to be harmed by the blister fluid. There is no mustard in these blisters and this is an Iranian casually who has darn near-ninety ninety-five per cent mustard burns. You can see the giant boy, he is red red red all over and he was a non-survivor.

The eye injury, mild conjunctivitis there’s, an intermediate which is more severe, takes longer to heal, with edema and even roughening of the cornea swelling and blepharospasm, and then there’s a severe category that can be so bad. There’s even perforation of the globe and it could even qualify for legal blindness. The breakdown on this is seventy-five per cent of them had mild conjunctivitis two weeks and it could be back to duty and they required little or no therapy. They just needed a lot of TLC. The fifteen per cent intermediate took some times as long as two months for six weeks more of a problem, but they would heal without residual. The remaining ten per cent were severe with residual damage and by today,’s, standards about the point.

One per cent of those patients would have met the criteria for legal blindness, and this is a blow-up of a picture of a moderately severe mustard conjunctivitis haemorrhage in the conjunctival. This is a blow-up of the burned up, larynx tongue, symptoms. The upper airway is going to be haemorrhage pain, hoarseness strider, you can imagine. I mean you’re not going to be feeling like singing any songs with trachea and larynx. It looks like that down lower you, ‘re, going to get blunt bronchospasm caused by the inflammation, all the bronchi, and then the pseudomembranes will develop and can plug up the airways with a massive massive mustard exposure. You can get hemorrhagic pulmonary edema now pulmonary edema is not normal, a feature of mustard. This is only with very massive exposure. It is a feature of some of the other agents, but not mustered only with massive massive exposure.

moval is what really counts here, because, no matter what the active ingredient is in these things, they don’t kill the agent as fast as I want to kill the very best thing to do come with it be to jump in a shower and Just shower yourself clean matter of fact: if I had adoption, I’d get in it and they’d have to pull me out of it. So remember it’s, physical removal, don’t get hung up on what you’re, using get it off of you by whatever means you got. That said – and we say this late decon protects the medical personnel on the facility that doesn’t mean the casualty. Couldn’t have gotten the agent off the mop suit. That was lying there and needs some. The media decon or it doesn’t mean that they didn’t have such a large amount that some could still be lying there, even though they got to you half an hour later so, when possible. With these liquid agents, you always decontaminate at the earliest possible time. This is all common sense for all medical folks.

Ok, it’s just supportive. Now down here, a raw denuded area always gets some kind of secondary mild superficial infection. Going on that’s. Why? With these mustard things that are raw and denuded, you would use whatever topical antibiotics. You have. You know the surge in the soulful mile on the bacitracin nice point. Whatever you got, it’s appropriate right off the bat systemic antibiotics IV. Antibiotics are held in reserve. You can get secondary cellulitis, you know with the redness and the infection, the staff you can get that and you have to watch foreign culture. If you do get it, then you use appropriate IV. Antibiotics, systemic analgesics. Anybody want to argue that that one case probably needed a little morphine once in a while, you use whatever analgesics are appropriate. That could be as little as aspirin or antihistamine all the way up to morphine. It is said, and I believe it from the literature.

I read that a goodly portion, the soldiers in World War, one died just from lack of modern-day IV fluids and electrolytes replacements mustard burns are said not to have the severe fluid requirements that a therm burn. Does those of you who know of treated. He said no, that thermal burns take a massive amount of fluids. Well, mustard burns require a lot of fluids, but they’re not supposed to require the massive amounts of a thermal burn, but they do require good IV fluids and electrolytes. I again it’s supportive. There are two things. I want to point out here with a mustard eye injury. You want to grease the rims of the eyelid. You know with optimal logic, ointment antibiotic, I only meant Vaseline. If that’s, all you got, but you want to keep the rims lubricate and the reason being is that conjunctivitis is going to produce plus Polly’s. It probably sterile pus, but if the eyelid is stuck together from the edema, the swelling and held together and that puss doesn’t drain out a sterile abscess just destroys tissue. You know Polly’s produce peroxides on. So you want that lid to be open and draining you know, so they can it doesn’t get trapped behind here.

This other point here: topical steroids in the eye. You know this is a chemical type burn and I’ve talked to lots of ophthalmologists and every one of my voice told me they would use topical steroids in this injury. We do not have the laboratory data to prove whether this is beneficial or not, but I would like to be the call the ophthalmologist there are instances. Obviously, if there’s a secondary infection, you don’t want to be using a topical steroid alone. Also, if the injury is too severe, if the integrity of the globe is breached, putting steroids in the eye and they go straight in – can cause you to know, glaucoma problems, and so I would, by and large right now leave it up to the ophthalmologist, but it Could be a very important part of their treatment? Sunglasses causes photophobia.

There was the first use for photophobia or sunglasses, a mustard World War. One you can. You could use topical anaesthetics in a couple of situations. I could have envisioned – and I sometimes address this as it passed it by. I can envision a casually coming in being semi, hysterical and a lot of pain, and you would need topical anaesthetics just to get them under control, so you could examine them that’s one appropriate use another one would be, as I said so you or the Ophthalmologist could examine them topical anaesthetics. How many have ever had a corner, corneal abrasion? It hurts, doesn’t it. I had one and my friend ophthalmologist says here: let me give you some codeine or Percocet or whatever it was in those days and me being a macho man. I am, I declined. I just took my patch and went on vacation and i suffered the next two days like you, wouldn’t leave because it was so painful, but I did have topical anaesthetics with me. Like a wise doctor, you know who should ever treat himself. You put the drops in 45 minutes goes numb. You feel wonderful. You probably could do yourself more damage. Why you don’t feel anything and guess what in five minutes it’s right back it doesn’t, you know you it doesn’t work long enough to do squat. Okay, all everything we know bronchodilators. The steroids here are four bronchospasms. They’re not for anti-inflammatory there’s, no indication that we have that it will knock out.

The inflammation is for bronchospasm atropine. This is not like in a nerve agent. This is like a preoperative dosage, like for cramping and diarrhoea, like point three milligrams that’s what this would be for nausea, vomiting diarrhoea if you have a cholinergic or gif x of mustard and we’ve talked the fluid and electrolyte replacement. You know we’re talking a lot of World War, One data in Iran, Iraq war, because we have we personally haven,’t had mustard thrown at us on a modern-day battlefield and I’m very grateful. So we’re talking about historical data. Animal data etc. I will bet you dollars to doughnuts that in a modern battlefield, if we weren’t overwhelmed it, wasn’t a true mass casualty scenario and you can get people back to a tertiary medical facility, these people that would have died. I bet we can save a lot of them and we’d save them with transfusions.

Okay, we get there are marrow transplants that work. Nowadays we may be able to do hormonal stimulation of the bone marrow erythropoietin anabolic steroids there. Some of these things may work and even just reverse isolation techniques to help with the bottom falling out of the bone marrow its mustard cards carcinogen. You bet you know there’s been a lot of talk about the Gulf War, illness, and what does this in? The mustard is absolutely a carcinogen and mutagen. There is no evidence to date of reproductive toxicity in humans. There is some animal data, reproductive toxicity and I know there was shown on television recently about the Kurds, which I didn’t see, and it suggested they may be bothered by reaper 60 minutes, but I didn’t get to see then, but I’m not going to argue the issue one way or another chronic exposure. Does it cause cancer in chronic exposures?

Absolutely there’s good clear data and people who have been factory workers in the manufacture of mustard who got bronchial cancers: okay, chronic bronchitis and emphysema. We don’t know – and I’ll tell you why, because they were primed, the best work was done by the British in a world after world war one and they had about twelve per cent or so of soldiers that end up with chronic bronchitis emphysema, but They were smokers. The air in England at that time was very polluted from burning coal with sulfur in it, and also these soldiers had also had a chronic lung bronchial infection that had to heal without antibiotics, so had very scarred bronchi, okay, so they did end up with chronic bronchitis And emphysema, so you can’t clearly say what caused what, but I won’t bet against it acutely. One or two exposures has no evidence that mustard causes cancer, chronic eye problems. Absolutely okay, you get high damage and stuff. You get chronic eye problems. A very you know: low percentage, Lois site, captain Lewis, World War, one that was Captain from the US by the way, has never been used, except possibly by the Japanese against China leading up the world war. Two, no other known, use sparse data on it. It is very similar to muster with some significant differences, ah mustard freezes, 5758 lucite freezing zero guess what happens when you mix mustard lewisite together, drops the freezing point down around zero? Where were we going to eat?

Where did we think world war three would be fought? Europe, where it would frequently below be blown, temperatures which had has lots and lots of mustard lewisite mixtures, you got it the former Soviet Union and they still got it heavier and air heavier and water. It’s. The oily substance, persistent said the smell like geranium, now mustard stinks, moisture smells like garlic, onions, mustard stinks and you can smell it at very low levels. If you have a good sense of smell and Lewis site said to smell like geraniums, so it’s supposed to smell, pleasantly is lewisite. Carcinogenic, arsenic is in the molecule lewisite. We don’t know that Lewis site is carcinogenic, but we know that arsenic is certainly a carcinogen. The exact mechanism of action Lewis site is unknown, but the primary pulmonary lesion in Lewis site is like that of mustard. It is necrosis to the bronchial epithelium, ok, but the exact mechanism is unknown eyes, Airways skin, just like mustard its primary epithelial targets, but look right here:’s, a new one, Lewis site damages capillaries, I didn’t say anything about capillaries with mustard Lewis Site damages capillaries and causes leakage. This is said to be a little site blister that you need to remember that is different from mustard. It damages Kepler’s causes leakages, yes, siree question: how would these be?

It was easily deployed baby panting to munitions, skidding uh. Getting him on the kid rod, would they be um sprayed and I just love it in the local area? Say your question. Yes, I said sir, would these be packed? What kind of initials would be packed into? Would they be sprayed on or would they be put like in artillery shells? Yes, yes, and this class is starting to pick up. You guys are saying you guys are flat. Yes, sir. This is why I like you can deliver this stuff anyway. It can be sprayed most commonly it is blown up. Ok is either dropped out of aeroplanes in an explosive thing, and you get an aerosol. You know the droplets that then can go on the vaporize. Ok, that’s pretty good. I like that lewis. I’d cause immediate pain, okay mustard. You got the delay, tific immediate pain in five minutes. You’re getting tissue, necrosis, big difference; okay, big difference, blisters said to cause more necrosis and mustard to the fact is. We have very little experience with us because it’s never been used on the modern battlefield very similar to mustard okay, except it’s going to be the immediate same as for mustard. Aha, remember I dwelled on the Kapler is one mechanism action away Lewis. I can take you out: is pulmonary demon death the capillaries get damaged? You’re getting fluids leaking into your alveoli. You get serious pulmonary oedema, Hema concentration, hypotension and circulatory collapse and death just a progression. You know the bottom falls out of your blood pressure.

You’re drowning in your own fluids, and it can take you out, Lewis. I can do that in the lung. Aha, there is a specific antidote for Lewis site, unlike mustard, which is totally supportive in World War, one they came up with British anti lewisite bow or dimercaprol most time you think you know, British anti lewisite bow VA el specific antidote against Lewis site. Remember I told you, arsenic is in the molecule. Lewisite bow is a heavy metal key later it chelates sup Louis light, and it does work it’s also used another heavy metal poisoning. Ok, it comes in all three forms: topical ophthalmologic and systemic don’t even memorize this. If I ever have to use this, I’m going to go to the little handbook and look up the mounts, but there are directions for using it. You ever heard that the treatments as bad as the cure. Well, there are side effects to bow. They’re, not showstoppers, but it’s kind of stuff. If you didn’t have to take it, you’d, rather not Bosnian oxime. I thought when i took this course 100 years ago it wasn’t bad enough. There were so many names and symbols they had to go. Have one called Fozzy, no one called phosgene oxime. Well, phosgene oxime is made from phosgene that’s. Why you get the name and see ex nazi g? It is not a blistering agent. It is a very corrosive substance that said to be an ER de. Can’t educate our deacons to cause a hive-like lesion before it goes ahead and rots your skin off? Very little known about it here,’s. Why we stay concerned about it.

They got it stockpiled. Ok, the former Soviet Union, and they still got it. It’s a very corrosive substance, while phosgene is only a lung, an agent that has no effects on the skin. Phosgene oxime is a corrosive epithelial agent, but oddly obviously, if you get this into the lungs, it also as pulmonary agent management. There’s no magic bullet. It’s, everything you know just like mustard, totally supportive. I would tell you, though, that with any liquid agents – and we’re talking about vesicles now today, but with any liquid agents, what’s the number one thing you do, if you can decontamination, okay, don’t forget that you’ll see it Again, this is a mini pickup truck from Saudi, okay and those are camels. Those are camels and the question is this: is your test question I promised you how many camels can ride in the mini back of a mini, pickup truck one wrong answer. The answer was too: if you just kept going up, you’d, eventually hit it right. There’s three, okay, three back there ones facing out this way. One’s face and right at me, and no one’s facing out that way, and I never cease to be amazed in Saudi. This is not even a long mini. This is one little me and it was three big camels sitting in the back that truck happy as larks just right on, and you saw I mean you can ask anybody else if they didn’t they saw this too, and I guess this just goes to show that camels are ready to ride a mild and walk a mile questions. Sir, could you mention anything about the topical skin protects skin protectant centre?

Yes good. We have developed this topical skin protectant here as all kind of side stories. I can tell on this, but I’m already over in it. If you grab me at the break, I can give you colour commentary on these, but we have a skin protectant that’s an advanced development and it’s made from a commercial. Well, we had to get the right texture and it’s got these particles and if there are actually Teflon particles – and you got to get the right mix and it protects, you can put it on your skin enclosure areas and it will increase your protection on The bearskin, the agents up to like four five-six hours and envision to be put in the closure areas – okay Institute and Colonel little – will talk to this. At the end of the course. We always bring me because we’d, like you to know we don’t touch on all the neat things: the stuff that’s going on here for the future, but there are lots of ideas for better protection down the line. We also work on a second-generation on what is called a reactive, topical skin protectant.

We’re and we’re trying a lot of different things, but they took the regular topical skin protectant that’s already in advanced development, and one thing we did in World War two they were experimenting with all these topical protectives. I brought some 80-year-old scientist up here, who is a guy in invented asst s330 in World War, two, he’s still alive PhD sharp his attack. We took his old material s330, put it in the new, topical skin protectant and it doubled the time of the current one and it’s reactive, destroy it. So they’re working on it. You know that may not ever be the second generation, but we got lots of good leads. Okay, yes, do any of the agents of the other agents of stay in the vesicles. No, not to my knowledge now the reason I made a point of bringing that out. Is there crackpots around the world that publish all kind of things and every few years somebody will come up with nairaland, say: aha, we found live mustard and a blister fluid that has been tested over and over again that’s, not true. Okay, I don’t want – and I’m not aware that any of the other ones would stick around. They react too fast. They’re kind of damaged tissue. I mean it is it doesn’t even make sense that they would still be there. Okay,