August 27, 2013 10:24 am
Inspectors from the United Nations are attempting to determine whether the Syrian government is responsible for the use of chemical weapons in attacks there—a line that, if crossed, could warrant intervention by outside nations. For doctors on the ground, though, the question is less who used the weapons and more how they are going to treat the victims. This morning the New York Times published a harrowing account of what hospitals are like right now:
Thousands of sick and dying Syrians had flooded the hospitals in the Damascus suburbs before dawn, hours after the first rockets landed, their bodies convulsing and mouths foaming. Their vision was blurry and many could not breathe.
Overwhelmed doctors worked frantically, jabbing their patients with injections of their only antidote, atropine, hoping to beat back the assault on the nervous system waged by suspected chemical agents. In just a few hours, as the patients poured in, the atropine ran out.
Atropine, the drug these doctors are using, is an extremely common drug. The World Health Organization has it on their “Essential Drugs List,” a list of drugs that constitute the baseline of medical care. It is also the most common drug used to combat nerve agents—the chemicals that block the communication between nerves and organs. The symptoms described by the Times—convulsions, foaming mouths, blurry vision, difficulty breathing—are all associated with the use of these nerve agents.
Understanding how atropine works depends on understanding how nerve agents work. Essentially, when the body is working normally, a neurotransmitter called acetylcholine moves between nerves to carry signals. Once the acetylcholine does its job, an enzyme shows up to break it down. Nerve agents destroy that enzyme. Acetylcholine builds up and continues to make the nerves connect over and over and over again.
Atropine, on the other hand, blocks the acetylcholine receptor. So even if there’s a huge buildup of acetylcholine between the nerves, the connection never happens. This, of course, can also be dangerous, because if your nerves can’t talk to one another your body can’t function. But in situations where the acetylcholine is unchecked, atropine can help stop seizures and convulsions. It must be dosed carefully, and administered quickly, but in nerve gas attacks it is really the only treatment doctors in Syria have.
Humans have known about the power of atropine for a long time. The active ingredient comes from plants in the Solanaceae family like nightshade, Jimson weed and mandrake. Egyptian women used atropine to dilate their pupils, to look more attractive, and the Greeks used it before surgery to numb pain. It wasn’t until 1901 that pure atropine was synthesized in the lab by combining tropine with tropic acid.
Today, it’s used for all sorts of things beyond chemical warfare. Doctors use it before anesthesia, it’s used during heart surgery, to dilate eyes during eye surgery, and to treat scorpion stings and other venomous bites.
Despite its many uses and its key role in fighting nerve agents, the atropine supply is relatively low. The doctors in Syria are running out of it, and in July the American Society of Health-System Pharmacists added atropine to the list of current drug shortages. They cite a few reasons for the drop in supply:
- American Regent had temporarily suspended manufacture of most drug products in April, 2011.
- American Regent resumed manufacturing in Shirley, New York in early-May, 2011.
- Hospira states the shortage is due to manufacturing delays.
- West-Ward acquired Baxter’s atropine injection products in May, 2011. NDC codes began changing for these products in early, 2012. West-Ward is not manufacturing the 0.4 mg/mL or 1 mg/mL 1 mL vials.
- Amphastar has atropine on shortage due to increased demand.
This isn’t the first time people have had to consider a dip in supply of atropine. In 2004, researchers at the NYC Poison Control Center looked at just how long after its shelf life doctors could use atropine in emergency situations. “A massive nerve agent attack may rapidly deplete in-date supplies of atropine,” they write.
Which seems to be exactly what’s happening in Syria. Doctors Without Borders estimates that in the past few months they’ve sent 1,600 vials of atropine. Ghazwan Bwidany, a doctor treating patients in Syria told the BBC that along with being understaffed, they were running out of medicine. “We are lacking medical supplies now, especially atropine,” he said.
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