The American College of Medical Toxicology
Educational Offerings in Chemical Terrorism and Hazardous Chemicals Response:
Chemical Agents of Opportunity for Terrorism:
The Medical and Psychological Consequences of TICs (Toxic Industrial Chemicals) and
TIMs (Toxic Industrial Materials)
AND
Health Consequences of Clandestine Methamphetamine Laboratories
“Chemical Agents of Opportunity for Terrorism: The Medical and Psychological Consequences of TICs (Toxic Industrial
Chemicals) and TIMs (Toxic Industrial Materials)” is a course that has been created by the American College of Medical Toxicology
(ACMT) to provide awareness-level training, cross-discipline interaction, and tabletop exercises regarding the potential use of
existing industrial compounds as terrorist weapons.
ACMT (www.acmt.net) is the professional organization of physician medical toxicologists and consists of ~500 members distributed
throughout the country working in academic, clinical, poison center, industrial and government settings. Medical toxicologists have
primary board training, generally in emergency medicine, pediatrics, occupational and preventive medicine, or internal medicine,
followed by additional fellowship subspecialty training and certification in medical toxicology. Medical toxicology is focused on the
toxic effects of exogenous substances on human beings; Medical Toxicology is a recognized subspecialty by the Accreditation
Council for Graduate Medical Education (ACGME; www.acgme.org).
Over the last seven years, the “TICs/TIMs Agents of Opportunity” course has been presented more than 60 times to more than 6500
people, including representatives from police, fire, EMS, hospital medical and nursing staff, emergency planners, public health and
environmental health personnel, state and federal regulatory personnel, FBI, and military personnel. In the past, this course has been
facilitated and supported by a contract with the Agency for Toxic Substances and Disease Registry (ATSDR) of the Centers for
Disease Control and Prevention (CDC).
We have added a number of enhancements to this course over the years, largely at the recommendation of previous participants.
These have included increased audience participation through the use of audience participation software and the introduction of
tabletop exercises focusing on prevention through Hazard Vulnerability Assessment and response to chemical releases.
We were recently invited to present this course by the 94th Civil Support Team (CST) of the National Guard in Guam. Based on that
successful course (with 200 participants over 2 days), we are proposing this course be offered to all 55 CSTs with each CST working
in collaboration with regional ACMT and ATSDR representatives to draw a cross-section of partners as participants.
The cost of the course inclusive of travel, per diem and honorarium for 4 ACMT lecturers and syllabi for up to 100 participants is
$18,000. Other costs, such as extraordinary travel expenses, extended versions or multiple days are negotiable.
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An outline of the course is attached as Appendix A
A listing of the courses given to date is attached as Appendix B.
A sample listing of past participants is attached as Appendix C.
A listing of comments from the participants at the Guam courses given this year is attached as Appendix D.
A listing of the ACMT regional directors is attached as Appendix E.
In addition, ACMT has developed a course on the “Health Consequences of Clandestine Methamphetamine Laboratories”, which has
been provided to more than 600 participants in more than 10 venues. See Appendix F for a brief overview of this course and list of
major past presentations.
We are interested in providing these educational conferences to the nations’ Civil Support Teams and their respective partners.
Please contact me or your regional ACMT Director if you have any questions.
Charles A. McKay MD FACMT, FACEP
Board of Directors, American College of Medical Toxicology (ACMT)
ACMT National Director, ACMT/ATSDR Network
(860) 545-5411 cmckay@harthosp.org
APPENDIX A:
Chemical Agents of Opportunity for Terrorism:
The Medical and Psychological Consequences of TICs (Toxic Industrial Chemicals) and
TIMs (Toxic Industrial Materials)
COURSE OBJECTIVES
The American College of Medical Toxicology (ACMT) is pleased to offer a 1-day course on: Chemical
Agents of Opportunity for Terrorism: The Medical and Psychological Consequences of TICs (Toxic
Industrial Chemicals) and TIMs (Toxic Industrial Materials). This course will provide awareness-level
training on a variety of toxic syndromes likely to be encountered following exposures to TICs and
TIMs and other chemical agents of opportunity. The course will focus on the medical and psychological
issues pertaining to TICs, TIMs as well as other important non-volatile chemical exposures.
In recent years, there has been growing concern that many of the most likely threats of chemical
terrorism involve so-called “agents of opportunity.” Both common and unusual industrial agents may
pose a considerable threat as potential terrorist weapons. While an understanding of the traditional
military chemical weapons (e.g. nerve agents) remains essential, an appreciation of the myriad of other
potential toxic chemicals readily available in our society is crucial if we are to optimally prepare,
identify and defend against chemical threats. This course will utilize a symptom-based clinical approach
to describe the medical impact of various chemical poisons. We will provide a framework to enhance
recognition of the common health effects of apparently disparate chemical toxins, describe the risk to
various healthcare workers, and introduce clinical and public health management strategies. The
traditional military warfare chemical agents will not be covered in these lectures because information
on these agents is readily accessible through a number of other forums such as the Internet.
By attending this one day course, the participant will be able to:
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Understand the concept of chemical agents of opportunity, TICs and TIMs and appreciate the
basis for increased public health preparedness
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Identify chemical agents of opportunity that could be used by terrorists
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Discuss the past use of these chemicals in mass exposure situations
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Describe the major health effects of TICs, TIMs and other important non-volatile chemical
agents that could be used by terrorists
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Identify the primary modalities available to treat victims of such chemical exposures
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Understand the psychological impact of mass chemical exposures
TARGET AUDIENCE
The information presented will be of interest to public health officials, emergency response
coordinators, FOSCs, environmental health scientists, toxicologists, occupational/environmental and
emergency physicians, veterinarians, laboratorians, engineers, industrial hygienists and others involved
with chemical terrorism preparedness and response.
COURSE FACULTY
The faculty members are board certified and fellowship trained physician medical toxicologists who are
members of the American College of Medical Toxicology (ACMT) and currently serve as consultants to
ATSDR. They have extensive experience directly caring for patients suffering from the ill-effects of
chemical agents and poisons. ACMT is the major professional organization of physicians specializing in
medical toxicology in the United States. In 1999 ACMT entered into a 5-year cooperative agreement
with ATSDR under the auspices of Program Announcement 99081: Program to Build Capacity to
Conduct Environmental Health Promotion Activities. This agreement was designed, in part, to enhance
educational outreach to heath care professionals on issues pertaining to environmental toxicology.
Recognizing the urgent need to improve the capacity of health professionals and public health officials
to respond knowledgeably and effectively to chemical terrorism and related mass chemical exposure,
the ACMT – ATSDR partnership has considerably expanded during the past year. A national network
now links medical toxicologists across the country with the 10 ATSDR regional offices. As part of this
partnership, ACMT developed this intensive one-day training course on the medical response to
chemical terrorism and mass chemical exposure incidents.
SAMPLE PROGRAM
8:30 – 9:15 AM
Toxic Warfare: Looking Beyond Conventional Chemical Weapons
While the threat of conventional chemical warfare has received much attention, and is the subject of tight
control measures and a program of planned chemical destruction, less interest has been paid to other
chemical agents that have great potential to wreak havoc on the civilian sector and produce mass
casualties. This talk will provide an overview of toxic warfare, TICs and TIMs, and key lessons from
history.
9:15 – 10:00 AM
The Clinical Neurotoxicology of Chemical Terrorism
The awesome complexity of the central nervous system makes it particularly vulnerable to poisons. This
lecture will provide insight into the expected clinical effects of potential terroristic poisons by highlighting
three distinct brain syndromes: psychedelia (hallucinations), sedation (coma) and seizures (convulsions).
10:00 – 10:15 AM
Break
10:15 – 11:00 AM
Toxic Gases in your Community
Chemical compounds are produced in massive quantities as part of America’s industrial complex. Many
of these compounds are amenable to use as large scale terrorist weapons. This talk will address a number
of chemicals, such as phosgene, chlorine, and anhydrous ammonia, which might be disseminated as
inhalational threats. Their pathophysiology, treatment, and potential sources in the community and in the
transportation system will be discussed.
11:00 – 11:45 AM
Why Are Cyanide and Fumigants So Worrisome
Of the numerous poisons that impair mitochondrial function, cyanide is probably the most likely to be
used in a chemical terrorism event, given its availability and the ease with which hydrogen cyanide
gas can be generated. Cyanide and fumigants such as methyl bromide, sulfuryl fluoride, chloropicrin and
the phosphides are among the most toxic TICs. This lecture will provide an overview of mechanism of
action, metabolism, clinical presentation and medical management, including antidote utilization.
11:45 – 1:00 PM
Lunch Break
1:00 – 1:45 PM
Recognizing Current Vulnerabilities: Threats to the Water Supply
Much concern has been raised about the safety of our nations drinking water. This presentation will
explore the potential threat of chemical terrorism through our water supply.
1:45 – 2:30 AM
Recognizing Current Vulnerabilities: Threats to Food, and Drug Supplies
This presentation will discuss the vulnerability of the food and drug supply as a vehicle for chemical
terrorism. Recent mass poisonings involving nicotine in food, and contamination of illicit drug supply
will be discussed. The potential problems relating to counterfeit pharmaceuticals will also be explored.
2:30 – 2:45 PM
Break
2:45 – 3:30 PM
Terrorism by Fear and Uncertainty: Delayed Toxic Syndromes
Previous experience in medical toxicology provides notable examples in which malice or mishap has
resulted in widely publicized episodes of group or mass poisoning whose presentation was delayed. The
toxicity of metals such as thallium and the organomercurials, and of halogenated hydrocarbons such as
dioxins and PCBs, will be discussed with particular reference to how poisoning with these agents presents
and why delay in symptom onset complicates response to potential incidents of toxic terrorism.
3:30 – 4:15 PM
Radiation
Toxic effects of exposure to radiation or radioactive isotopes are good examples of delayed-onset toxicity.
This module reviews the terminology of radiation physics and provides examples of 5 major potential
sources of radiation exposure. The important difference between exposure and contamination, the role of
specific testing, supportive care, and specific therapy for various radioisotopes will be covered.
4:15 – 5:00 PM
The Psychological Impact of Mass Chemical Exposures
It is often difficult to differentiate psychological harm caused by chemical or biological terrorism from
other illnesses. Previous events demonstrate that large numbers of patients with psychological distress
will impact the emergency response and potentially overwhelm the health care system. Strategies must be
developed to diminish fear and hopefully decrease subsequent mass psychogenic illness that is likely to
occur following a mass chemical exposure.
APPENDIX B: Listing of TICs/TIMs: Chemical Agents of Opportunity courses to date
(62 courses planned; 59 courses held, with more than 6500 attendees)
Date
Jan-03
Sep-03
Oct-03
Jan-04
Jan-04
Apr-04
Apr-04
Aug-04
Aug-04
Sep-04
Oct-04
Oct-04
Nov-04
Dec-04
Dec-04
Feb-05
Mar-05
Mar-05
Jun-05
Jun-05
Aug-05
Sep-05
Oct-05
Nov-05
Nov-05
Dec-05
Dec-05
Mar-06
Apr-06
Apr-06
May-06
May-06
May-06
May-06
May-06
Aug-06
Sep-06
Sep-06
Oct-06
Oct-06
Nov-06
Nov-06
Feb-07
Feb-07
Apr-07
Jun-07
Jun-07
Aug-07
Sept-07
Nov-07
Dec-07
Jan-08
Apr - 08
Apr - 08
May - 08
May – 08
Region
National
5
National
2
National
4
7
2
3
8
5
8
10
3
10
8
1
1
3
3
National
10
6
9
10
1
9
10
1
9
1
6
7
9
9
National
3
9
2
5
9
9
1
9
9
2
National
National
10
9
9
4
7
9
10
4
July- 08
Aug-08
9
National
Venue
Audience Size
Comments
Atlanta / CDC
280
St. Charles, IL
80
Washington DC
250
New York, NY
90
Washington, DC
50
Birmingham, AL
130
Kansas City, KS
140
New York, NY
160
2 courses
Baltimore, MD
400
Breckenridge, CO 70
Detroit, MI
300
Helena, Montana
180
Seattle, WA
180
Charlottesville, VA 155
Portland, OR
120
Las Vegas, NV
50
Hartford, CT
65
Wallingford, CT
39
Philadelphia, PA
212
Charlottesville, VA 125
Louisville,KY
130
Force Health Protection-CHPPM
Seattle, WA
80
Plano, TX
30
San Francisco, CA 130
Anchorage, AS
100
Portland, ME
45
Coarsegold, CA
25
Spokane, WA
75
Hanover, NH
50
Sacramento, CA
200
Providence, RI
25
Laredo, TX
-Cancelled, weather
Omaha, NE
32
San Francisco, CA 125
Monterey, CA
60
Albuquerque,NM
60
Force Health Protection-CHPPM
Charleston, WV
180
Chula Vista, CA
100
“Border” course
Albany, NY
70
Cincinnati, OH
72
Las Vegas, NV
60
Clark County HazMat EXPLO2006
Orange County, CA
100
Pittsfield, MA
39
Honolulu, HI
170
2 courses
Palos Verde, CA
120
LA County Health Dept
Edison, NJ
60
Atlantic City, NJ
-Cancelled, low registration (NEHA pre-symp)
Louisville,KY
80
Force Health Protection-CHPPM
Bend, OR
25
Las Vegas NV
60
HazMat EXPLO2007
Oakland, CA
200
Orlando, FL
32
International Disaster Management Course
Hutchinson, KS
-Cancelled, low registration
Reno, NV
75
Winatchee, WA
~60
2 one-half day courses
Knoxville, TN
150
(UT and ~12 web/videoconf sites in 2 day course with
REAC/TS incl. DHS, CDC, DOE, others)
Guam
200
2 one-day courses fully supported by 94th CST
Albuquerque, NM
100
Force Health Protection - CHPPM
APPENDIX C: REPRESENTATIVE LIST OF PARTICIPANTS IN PAST TICs/TIMs
CONFERENCES
(alphabetical, non-exhaustive)
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Army National Guard Civil Support Team members
Air Force Personnel
Army Personnel
Civil Air Patrol
Coroner’s Office
Department of Environmental Services/Department of Environmental Protection, State
Department of Fish and Game, State
Department of Homeland Security, State
Department of Homeland Security, U.S.
Department of Public Health, City
Department of Public Health, County
Department of Public Health, State
Disaster Medical Assistance Team
Emergency Medical Technician
Emergency Medical Technician, Paramedic
Environmental Protection Agency, U.S. (EPA)
Federal Bureau of Investigation (FBI)
Federal Emergency Management Agency (FEMA)
Fire Department, City
Fire Department, County
Hospital Staff, Administration
Hospital Staff, Emergency Preparedness
Hospital Staff, Nurse
Hospital Staff, Physician
Hospital Staff, Security
Medical Examiners
Navy
Poison Center Staff, Nurse
Poison Center Staff, Pharmacist
Poison Center Staff, Physician
Police Department, City
Private Laboratories and Industries
Sanitation, County
School Health, Nurse
School Health, Physician
Sherriff’s Department, City
U.S. Food and Drug Administration (FDA)
U.S. Postal Inspection Service
Water Quality Control Board, Regional
APPENDIX D: SAMPLE OF RESPONSES FROM PAST COURSES (94th CST, Guam, July 2008)
What did you like best about the course?
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That I learned a lot and had many questions answered
Vast knowledge by instructors
How chemical agents/materials affect the environment
Very informative
How it was presented
Case studies relative to chemical threats; interactive votes were a good way to engage audience
Opportunity to know more about chemicals and what they do
Neurotoxicology
Quality of presentations and information
Module 5
Audience participation system
The personal informational guide to survival, well informative! Most especially the instructors.
Great toxicology principals learned.
Presenters were very informative
Threats to water, food and supply
Lecturer’s knowledge and expertise
Real world examples/applications provided firm support to theory and procedure.
Interaction with other agencies
Informative, location and food
Information and awareness
Different approach on each chemical for responders in the field
Understanding chemical hazards of incident
Module 5 – Chemical Contamination of Food, Water and Medication
The course is informative, especially the 5 & 6 topics
The different poisonous chemicals and their effects on people & interactive device.
The history of events and chemicals and relates to disaster nursing.
General information on the different chemicals that are a potential threat to our community
Variation of teaching (lesson) contents
Well organized. Good breaks. Good speakers.
The recognition of threats, terrorism and hazards. The audience response remote.
The interactive part of the powerpoints
Very good information with knowledgeable instructors
Content and relevance
Multi-agency venue
Very educational. Presenters were good and presented each topic well and easy to understand
Overall topics were very comprehensive and informative
Curriculum, expertise of instructors
Course broken down by manageable modules
Training was very informative and afforded me to come up with operational ideas for my job programs.
Very informative, identified industrial sources, as well as toxicological effects
Appreciated the slide presentations as handout
As a non-medical person, the course was easy to understand
Specific case information
Presenters were good; information related to my field of work.
Examples of case studies
All topics are relevant to my present job.
I’m glad the presenters followed the modules. The chemical presentation on Neurotoxicology was quite interesting.
Why are cyanide and fumigants so worrisome
Topic on the safety of US medications
All topics had different information and were not repetitive. Having different course presenters made it more interesting (vs. one
presenter)
Very informative and helpful to know more of what’s out there
Clear talks with a little joking makes it worth listening to.
Overall the course is great. A lot of useful, valuable info.
Toxic cases in your community
Knowing the effect is has on me and the island. The various chemical agents that are out there to include the foreign countries.
Presentations of actual cases were an eye opening reality check.
Good mix of layman and technical terms. Easy to follow.
 Many real world examples gave lessons the necessary impact for the importance of understanding toxic events.
Please provide additional comments or observations you wish.
 I’m happy that this program exists to help relevant agency employees to keep abreast of toxic issues. Also to provide an
opportunity for networking. The instructors were engaging and obviously intelligent, knowledgeable and articulate.
 Knowledge provides stability for preparedness and prevention of chemical chaos.
 Presentations to this important information should have more video/photos of real life effects of not taking their work serious
enough to be safe at all times.
 I wish this training could be conducted every year to refresh the attendees. There is a lot of information that is applicable not only
in times of emergency but also in every day activities both at work and at home.
 Antidote kits not available – and if they are, the kits are too expensive for our government to purchase. Our island is far, but the
potential for terrorism is there. We’re a melting pot of different ethnicities.
 Provide emergency kits, if available.
 I would prefer this course to be divided into two consecutive days to receive more information in detail.
 More on chemical and industrial events/disaster
 Gained better knowledge because presenters are with medical background.
 Instructors were very knowledgeable and seemed to really enjoy teaching us.
 Audience should participate more in the questions and answer, especially after every module.
APPENDIX E: ACMT REGIONAL CONTACTS FOR ACMT/ATSDR NETWORK
MAP REMOVED FROM FILE
National (and Region 1):
Region 2:
Region 3:
Region 4:
Region 5:
Region 6:
Region 7:
Region 8:
Region 9:
Region 10:
Charles McKay cmckay@harthosp.org
Lewis Nelson lnelsonmd@gmail.com
Kevin Wallace klw2hd@hscmail.mcc.virginia.edu
Michael Beuhler Michael.Beuhler@carolinashealthcare.org
Curtis Snook
Snook.Curtis@epamail.epa.gov
John Haynes
jhaynes@elp.rr.com
Jennifer Lowry Jlowry@cmh.edu
Scott Phillips
SPhillips@newfields.com
Paul Wax
paul.wax@gmail.com
Tom Martin
tgm@u.washington.edu
ACMT/ATSDR Cooperative Agreement Coordinator:
Michael Kosnett Michael.Kosnett@uchsc.edu
(860) 545-5411
(212) 447-8150
(434) 882-3947
(704) 512-3750
(915) 545-7333
(913) 588-7109
(303) 815-1960
(602) 881-5966
(206) 598-4219
(303) 571-5778
APPENDIX F: Health Consequences of Clandestine Methamphetamine Laboratories
COURSE OBJECTIVES
Methamphetamine abuse is a growing problem in many areas of the country. While <2% of young adults
admit to current or recent use of methamphetamine, the number who are abusing and dependant on this drug is
increasing. The health and social consequences extend beyond the individual psycho-stimulant effects. While
“behind the counter” restrictions on access to some ingredients has had a tempering effect on meth lab
proliferation, the continued availability of reagents and the hazardous waste created in the manufacture of this
drug raise concerns about exposure to responders and cleanup/re-occupancy procedures. Of particular concern
is the exposure of children in this setting to some of the corrosive by-products of methamphetamine
manufacture. This course covers the acute and chronic health effects of methamphetamine and its illicit
manufacture from the medical, social, and legal perspectives.
By attending this one-day course, the participant will be able to:
 Describe the state of methamphetamine use and clandestine methamphetamine laboratories in the U.S.
 Identify the clinical effects of methamphetamine and describe the management of acute and chronic
toxicity
 Describe the law enforcement perspective on methamphetamine in the community
 Describe the chemical hazards of methamphetamine synthesis
 Identify personal and environmental protection equipment to be used by first responders
 Identify the modalities available to treat victims of the clandestine methamphetamine lab exposure
 Identify the occupational monitoring requirements for responders
 Identify the special features to be considered for the evaluation of children found at the scene
Health Consequences of Clandestine Methamphetamine Laboratories Courses To Date
Date
Region
Location
Attendees
Mar-06
Sept-06
Jan-07
9
4
5
Phoenix, AZ
Atlanta, GA
Detroit, MI
~70
~80
~100
May-07
May-07
Sept-07
Mar-08
Mar-08
3
3
1
3
9
Washington, DC
Philadephia, PA
Plymouth, MA
Harrisburg, PA
Los Angeles, CA
~45
~25
80
~25
~80
May-08
7
Omaha, NE
~75
Comments
ACMT Spring Symposium
given at CDC
available at
http://www.chmkids.org/default.aspx?id=806&sid=1
3 hr - Yankee2007 Health Sanitarian course
PA DPH and DEP
two-day course with tabletop exercise on second day (~80
registrants Day 1; ~45 for Day 2)
90 registrants; incl. multidisciplinary tabletop exercise