dealing with casualties of this type, together with the lack of optimized treatment protocols and the possibility that there are no appropriate drugs.

To enable the medical system to respond to a large number of chemical casualties, several issues must be addressed. First, casualties still contaminated with chemical agents are likely to present at hospitals. To avoid contaminating medical personnel and facilities as well, there must be accepted protocols for decontaminating and handling these casualties. Second, in an attack on a population center, experience suggests that for every legitimate patient presenting at the hospital, between 100 and 1,000 “worried well” will also arrive, looking for reassurance. Hospitals have no capability to manage crowds or to triage large numbers of anxious people. Third, the U.S. hospital system—in the interests of efficiency—has slimmed down to the point that there is essentially no capacity for surges in demand for medical care. Thus there are not enough beds, medical supplies, and respirators to deal with any substantial number of terrorist-event casualties.

Recognizing that the medical system is ill prepared to handle a massive influx of chemical casualties is not the same as knowing how to prepare for such an event. A great deal of work can be done with computer modeling and tabletop exercises, but only through field exercises will the real weaknesses in the system be discovered. Carrying out exercises of this type is expensive, however, and can raise the public’s level of anxiety. Deciding on the best course to pursue in preparing for the possibility of mass casualties is an issue of policy, but resolving the technical details requires a balance between paper or computer exercises and checks of reality.

Recommendation 4.19: With the collaboration of hospitals and medical associations, FEMA should lead a careful systems analysis of needs—covering doctors, facilities, supplies, and equipment—for responding to plausible large-scale chemical attacks. This analysis should be used as the basis for planning the acquisition, storage, and distribution of resources in preparation for such attacks.

Recommendation 4.20: The federal government should work with the private sector to develop plans to provide surge capacity and to conduct exercises with the full participation of the medical system.

Recommendation 4.21: The federal government should provide leadership in developing strategies for training medical personnel in appropriate responses to chemical injuries and for stockpiling associated medical supplies.

Treatments for chemical casualties have come primarily from military medicine and are intended to preserve soldier function. Whether these protocols are optimal for civilian casualties has not been resolved or even carefully considered. The issue of long-term damage to the central nervous system is particularly

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