| ||||||||||||||||||||||||||||||
|
||||||||||||||||||||||||||||||
| Copyright © 2010. National Academy of Sciences. All rights reserved. Terms of Use and Privacy Statement |
Below are the first 10 and last 10 pages of uncorrected machine-read text (when available) of this chapter, followed by the top 30 algorithmically extracted key phrases from the chapter as a whole.
Intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text on the opening pages of each chapter.
Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.
Do not use for reproduction, copying, pasting, or reading; exclusively for search engines.
OCR for page R1
Assessing Medical Preparedness to Respond to a Terrorist Nuclear Event: Workshop Report
ASSESSING MEDICAL PREPAREDNESS TO RESPOND TO A TERRORIST NUCLEAR EVENT
WORKSHOP REPORT
Committee on Medical Preparedness for a Terrorist Nuclear Event
Georges C. Benjamin, Michael McGeary, and Susan R. McCutchen, Editors
Board on Health Sciences Policy
INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES
THE NATIONAL ACADEMIES PRESS
Washington, D.C.
www.nap.edu
OCR for page R2
Assessing Medical Preparedness to Respond to a Terrorist Nuclear Event: Workshop Report
THE NATIONAL ACADEMIES PRESS
500 Fifth Street, N.W. Washington, DC 20001
NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine.
This study was supported by a contract between the National Academy of Sciences and the U.S. Department of Homeland Security (Contract HSHQDC-08-C-00014). Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the author(s) and do not necessarily reflect the view of the organizations or agencies that provided support for this project.
International Standard Book Number-13: 978-0-309-13088-2
International Standard Book Number-10: 0-309-13088-3
Additional copies of this report are available from the
National Academies Press,
500 Fifth Street, N.W., Lockbox 285, Washington, DC 20055; (800) 624-6242 or (202) 334-3313 (in the Washington metropolitan area); Internet, http://www.nap.edu.
For more information about the Institute of Medicine, visit the IOM home page at: www.iom.edu.
Copyright 2009 by the National Academy of Sciences. All rights reserved.
Printed in the United States of America
The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin.
COVER: The cover depicts a schematic model of the effects of detonating a 10-kiloton (kt) nuclear device at ground level in the central business district of a large metropolitan area. The circles around ground zero represent areas of extensive immediate damage from the blast (red), thermal (orange), and radiation (yellow) effects of the detonation. For illustrative purposes, the circles are not drawn to scale (in a 10-kt detonation, they would be nearly overlapping). The long elliptical contour lines emanating from ground zero represent the area where radioactive fallout would settle soon after a detonation, after being carried by atmospheric winds. The red ellipse represents the area in which the short exposure of anyone outdoors immediately after the detonation would probably be lethal. The orange and yellow ellipses represent areas of progressively less radiation. The H’s are hospitals and represent the likelihood that some hospitals, which tend to concentrate in the downtown of most central cities, would likely be affected negatively by a 10-kt nuclear detonation—some by the immediate effects, others by the fallout, and some by both.
Suggested citation: IOM (Institute of Medicine). 2009. Assessing medical preparedness to respond to a terrorist nuclear event: Workshop report. Washington, DC: The National Academies Press.
OCR for page R3
Assessing Medical Preparedness to Respond to a Terrorist Nuclear Event: Workshop Report
“Knowing is not enough; we must apply.
Willing is not enough; we must do.”
—Goethe
INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES
Advising the Nation. Improving Health.
OCR for page R4
Assessing Medical Preparedness to Respond to a Terrorist Nuclear Event: Workshop Report
THE NATIONAL ACADEMIES
Advisers to the Nation on Science, Engineering, and Medicine
The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences.
The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Charles M. Vest is president of the National Academy of Engineering.
The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine.
The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. Charles M. Vest are chair and vice chair, respectively, of the National Research Council.
www.national-academies.org
OCR for page R5
Assessing Medical Preparedness to Respond to a Terrorist Nuclear Event: Workshop Report
COMMITTEE ON MEDICAL PREPAREDNESS FOR A TERRORIST NUCLEAR EVENT
GEORGES C. BENJAMIN (Chair),
American Public Health Association, Washington, DC
GEORGE J. ANNAS,
Department of Health Law, Bioethics and Human Rights, Boston University School of Public Health, Boston, MA
DONNA F. BARBISCH,
Global Deterrence Alternatives, LLC, Washington, DC
FREDERICK M. BURKLE, JR.,
Center for Refugee and Disaster Studies, Johns Hopkins University Medical Institutions and Harvard Humanitarian Initiative, Kailua, HI
COLLEEN CONWAY-WELCH,
Vanderbilt University School of Nursing, Nashville, TN
DANIEL F. FLYNN,
Caritas Holy Family Hospital and Medical Center, Methuen, MA
RICHARD J. HATCHETT,
Radiation Countermeasures Research and Emergency Preparedness, National Institute of Allergy and Infectious Diseases, Bethesda, MD
FRED A. METTLER, JR.,
Radiology and Nuclear Medicine, New Mexico Federal Regional Medical Center, and Department of Radiology, University of New Mexico School of Medicine, Albuquerque, NM
JUDITH A. MONROE,
Indiana State Department of Health, Indianapolis, IN
PAUL E. PEPE,
University of Texas Southwestern Medical Center at Dallas; City of Dallas Medical Emergency Services for Public Safety, Public Health and Homeland Security; Dallas Metropolitan Medical Response System; and Metropolitan Biotel System, Dallas, TX
THOMAS M. SEED, Consultant,
Tech Micro Services, Bethesda, MD
JAMES M. TIEN,
College of Engineering, University of Miami, Coral Gables, FL
ROBERT J. URSANO,
Department of Psychiatry, Uniformed Services University of the Health Sciences, Bethesda, MD
Study Staff
MICHAEL McGEARY, Study Director
WILLIAM F. STEPHENS, Consultant
SUSAN R. McCUTCHEN, Senior Program Associate
ANDREW POPE, Director,
Board on Health Sciences Policy
OCR for page R6
Assessing Medical Preparedness to Respond to a Terrorist Nuclear Event: Workshop Report
This page intentionally left blank.
OCR for page R7
Assessing Medical Preparedness to Respond to a Terrorist Nuclear Event: Workshop Report
Reviewers
This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the National Research Council’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report:
Herbert L. Abrams, Department of Radiology, Professor Emeritus, Stanford University
Brooke Buddemeier, Global Security Directorate, Lawrence Livermore National Laboratory
Michael L. Freeman, Vanderbilt University School of Medicine
Dan Hanfling, Emergency Management and Disaster Medicine, Inova Health System
Nathaniel Hupert, Weill Cornell Medical College
Although the reviewers listed above have provided many constructive comments and suggestions, they did not see the final draft of the report before its release. The review of this report was overseen by Ms. Hellen Gelband, Resources for the Future. Appointed by the Institute of Medicine,
OCR for page R8
Assessing Medical Preparedness to Respond to a Terrorist Nuclear Event: Workshop Report
she was responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution.
OCR for page R9
Assessing Medical Preparedness to Respond to a Terrorist Nuclear Event: Workshop Report
Preface
The 20th century brought us the birth of the atomic age, with Albert Einstein’s understanding that E = MC2 in 1905, Ernest Rutherford’s theory of the structure of the atom in 1911, and the first sustained nuclear reaction in Chicago in 1942. While it brought the promise of a robust use of nuclear technologies for peaceful purposes, it also brought the reality of nuclear weapons in 1945. Those initial weapons were large, heavy, and complex to make and use. Moreover, only nations had nuclear weapons, not individuals or groups. Since then, nuclear weapons technology has continued to advance, producing smaller, lighter, and more potent weapons. In addition to that technological advance, terrorists are working diligently to obtain those devices. Today, the development and detonation of a compact and portable nuclear device by a small group of terrorists is a potential threat.1 Such an improvised nuclear device (IND) could be small enough to transport in a vehicle and could produce an explosion equal in yield to 10 kilotons (kt) of TNT (trinitrotoluene).2
Like other nuclear weapons, an IND detonation would result in substantial structural and environmental destruction from blast, heat, and radiation effects. That destruction would impose a significant additional burden on the normal disaster emergency medical response because of the extent of physical destruction, the presence of dangerous levels of radiation, and the potential loss of critical medical infrastructure in surrounding areas. Numerous operational and logistical problems with delivering supplies, transporting patients, and emergency communications would further complicate the response.
OCR for page R10
Assessing Medical Preparedness to Respond to a Terrorist Nuclear Event: Workshop Report
The medical impacts of those injuries are likely to be catastrophic, both for people in the immediate area and for those in a radius of up to several miles. Survivability is related to a combination of the degree and type of injury and the degree of exposure to radiation in both the short and intermediate terms. Those effects have both medium- and long-term health consequences for victims and emergency response personnel. Under any scenario envisioned from the release of an IND, we will have a significant medical disaster with thousands of casualties. The immediate requirement for a large number of specialized beds for burns, broken limbs, head injuries, crushed lungs, eye injuries, and other types of trauma will overwhelm the current health system, which is already overtaxed.3 The number and variety of casualties, the lack of adequate emergent health care infrastructure in many areas (including burn and trauma beds, respirators, supplies, and trained staff), and the long-term disruption to routine emergent and urgent health care services represent a significant planning challenge.
In addition to the devastation around ground zero from blast, thermal, and prompt radiation effects, a ground-level detonation would create a substantial amount of fallout that would be deposited for miles downwind. Radiation from the fallout would cause death and injury to people exposed to it, especially those outdoors in the first 10-15 miles downwind during the first few hours, but efforts to prepare the public to take the appropriate steps to protect themselves from fallout are almost nonexistent.
Disasters also have serious psychological impacts on people who are involved in them.4 In general, we are not well prepared to help victims cope with the psychological effects of disasters, and terrorist nuclear events are no exception.
The United States has been struggling for some time to address and plan for the threat of nuclear terrorism and other weapons of mass destruction (WMDs) that terrorists might obtain and use. One of the earliest medical preparedness efforts, the Metropolitan Medical Response System Program, was started in 1995, but it has remained underfunded and its potential has been largely unfulfilled.5 A range of public health efforts have been taken to prepare for the appearance of pandemic influenza, smallpox, anthrax, and other infectious disease threats. Those efforts have put some systems and some resources in place, such as the National Disaster Medical System, to respond to infectious and other health emergencies, but as Hurricane Katrina showed, they are not adequate to overcome a substantial loss of critical medical and response infrastructure.
There are, of course, a number of public and nonpublic efforts by a variety of federal, state, and local agencies to prevent, mitigate, and respond to the threat of an IND. The latest effort, the Urban Area Security Initiative (UASI), is providing funds to 45 urban areas to improve preparedness for WMDs, including an IND detonation. The Department of Homeland
OCR for page R11
Assessing Medical Preparedness to Respond to a Terrorist Nuclear Event: Workshop Report
Security, as directed by Congress, asked the Institute of Medicine (IOM) to conduct a workshop to better understand the state of preparedness for an IND detonation in the six UASI cities designated as “Tier 1.” Public health practitioners are usually asked to figure out how to prevent bad things from happening and to preserve our health. The basic assumption for this workshop, however, was to assume: What if? Specifically, what if the efforts by law enforcement and other security officials failed to prevent the detonation of a 10-kt nuclear device in a central city? The committee’s task was basically to ask: Where are we today, and what are the gaps should the unthinkable happen? The committee fulfilled that task.
This report provides a frightening but candid look into our level of preparedness today. It was an informative process; one that did much to confirm that we are not yet prepared for a nuclear event. In fact, in many ways, we are still in the infancy of our planning and response efforts. The workshop identified several key areas in which we might begin to focus our national efforts in a way that will improve the overall level of preparedness.
The workshop committee members were a group of some of the most intelligent and wisest people in the areas of emergency preparedness and nuclear response. In addition, the many panel members who contributed to the workshop brought a great deal of technical knowledge and practical reality to the discussion. That contribution was of particular value concerning the status of preparedness of the Tier 1 UASI cities.
In closing, I would like to thank the IOM staff who supported this committee’s work, and the committee members with whom I had the pleasure to work. The workshops were complicated, the deadlines tight, and the material complex. The staff did a terrific job, and I was honored to have the opportunity to work with them.
Georges C. Benjamin, M.D., Chair
Committee on Medical Preparedness for a Terrorist Nuclear Event
Endnotes
1. Allison, G. 2004. Nuclear terrorism: The ultimate preventable catastrophe. New York: Times Books, Henry Holt and Company; Commission on the Prevention of Weapons of Mass Destruction Proliferation and Terrorism. 2008. World at risk: The report of the Commission on the Prevention of WMD Proliferation and Terrorism. New York: Vintage Books; Statement for the Record of Charles E. Allen, Under Secretary for Intelligence and Analysis, U.S. Department of Homeland Security, Before the Senate Committee on Homeland Security and Governmental Affairs, Hearing on Nuclear terrorism: Assessing the threat to the homeland, April 2, 2008.
2. Bunn, M. 2008. The risk of nuclear terrorism—and next steps to reduce the danger. Prepared testimony for the Senate Committee on Homeland Security and Governmental Affairs, Hearing on Nuclear terrorism: Assessing the threat to the homeland, April 2, 2008.
OCR for page R12
Assessing Medical Preparedness to Respond to a Terrorist Nuclear Event: Workshop Report
3. IOM (Institute of Medicine). 2007. Hospital-based emergency care: At the breaking point. Washington, DC: The National Academies Press.
4. IOM. 2003. Preparing for the psychological consequences of terrorism: A public health strategy. Washington, DC: The National Academies Press.
5. IOM. 2002. Preparing for terrorism: Tools for evaluating the Metropolitan Medical Response System Program. Washington, DC: The National Academies Press.
OCR for page R13
Assessing Medical Preparedness to Respond to a Terrorist Nuclear Event: Workshop Report
Contents
ABBREVIATIONS AND ACRONYMS
xvii
INTRODUCTION
1
COMMITTEE PROCESS
4
WORKSHOP ASSUMPTIONS AND TOPICS
5
Assumptions,
5
Topics,
6
TOPIC 1:
EFFECTS OF A 10-kt IND DETONATION ON HUMAN HEALTH AND THE AREA HEALTH CARE SYSTEM
7
Health Effects,
9
Effects on the Area Health Care System,
20
Discussion of Health Effects and Health Care System Impacts,
23
Summary of 10-kt Detonation Effects,
24
TOPIC 2:
MEDICAL CARE OF VICTIMS OF THE IMMEDIATE AND FALLOUT EFFECTS OF A 10-kt IND DETONATION
27
Discussion of Medical Care of Victims of a Nuclear Detonation,
31
TOPIC 3:
EXPECTED BENEFIT OF RADIATION COUNTERMEASURES
32
Discussion of Radiation Countermeasures,
41
OCR for page R14
Assessing Medical Preparedness to Respond to a Terrorist Nuclear Event: Workshop Report
TOPIC 4:
PROTECTIVE ACTIONS AND INTERVENTIONS IN THE EVENT OF A 10-kt IND DETONATION
42
Discussion of Protective Actions and Interventions,
47
Summary of Protective Action Guides,
48
TOPIC 5:
RISK COMMUNICATION, PUBLIC REACTIONS, AND PSYCHOLOGICAL CONSEQUENCES IN THE EVENT OF A 10-kt IND DETONATION
49
Discussion of Risk Communication, Public Reactions, and Psychological Consequences,
60
SUMMARY OF KEY POINTS FROM THE JUNE WORKSHOP
62
TOPIC 6:
FEDERAL AND STATE MEDICAL RESOURCES FOR RESPONDING TO AN IND EVENT
64
Discussion of Federal and State Medical Resources for Responding to an IND Event,
74
TOPIC 7:
CURRENT PREPAREDNESS FOR RESPONDING TO THE IMMEDIATE CASUALTIES OF AN IND EVENT
76
Panel 1 on Capability to Reach, Triage, and Treat the Injured,
78
Panel 2 on Capacity to Transport Casualties to Local Treatment Facilities,
82
Panel 3 on Preparedness of the Metropolitan Area’s Medical System,
84
Panel 4 on Preparedness to Evacuate Serious Casualties from the Metropolitan Area,
87
General Discussion of Topic 7: Preparedness for Responding to the Immediate Casualties of an IND Event,
94
TOPIC 8:
CURRENT PREPAREDNESS TO PREVENT AND TREAT THE DELAYED CASUALTIES OF AN IND EVENT
96
Discussion of Preparedness to Prevent and Treat the Delayed Casualties of an IND Detonation,
104
WRAP-UP AND FINAL THOUGHTS
107
REFERENCES
110
APPENDIXES
A
Workshop Agendas
115
B
Registered Workshop Attendees
131
C
Biographical Sketches of Workshop Speakers and Panelists
138
D
Biographical Sketches of Committee Members, Consultant, and Staff
160
OCR for page R15
Assessing Medical Preparedness to Respond to a Terrorist Nuclear Event: Workshop Report
Tables, Figures, and Boxes
TABLES
1
Estimated Acute Symptom and Death Rates from Radiation as a Function of Short-Term Whole-Body Absorbed Dose,
15
2
Treatment Strategies for Hematopoietic ARS,
37
FIGURES
1
Sources of injury from a 10-kt IND: approximate blast, thermal, and prompt radiation effects around—and fallout effects down-wind from—the detonation point,
10
2
Protection from exposure to radiation provided by sheltering in different types of structures and various places within those structures,
19
BOXES
1
Modeling the Effects of INDs in Modern U.S. Cities and Implications for Response and Recovery Plans,
11
2
Prompt Effects Summary,
13
3
Radiation Unit Equivalencies,
14
4
Fallout Effects Summary,
17
5
Nuclear Incident Communication Planning,
95
OCR for page R16
Assessing Medical Preparedness to Respond to a Terrorist Nuclear Event: Workshop Report
This page intentionally left blank.
OCR for page R17
Assessing Medical Preparedness to Respond to a Terrorist Nuclear Event: Workshop Report
Abbreviations and Acronyms
AFRRI Armed Forces Radiobiology Research Institute
AMS Aerial Measuring System
ARAC Atmospheric Release Advisory Capability
ARS acute radiation syndrome
ASPR Assistant Secretary for Preparedness and Response (HHS)
CBRN chemical, biological, radiological, or nuclear
CBRNE chemical, biological, radiological, nuclear, or explosive
CDC Centers for Disease Control and Prevention
CERFP CBRNE Enhanced Response Force Package
cGy centigray
CIMS citywide incident management system (New York City)
CMOC catastrophic medical operations center (Texas)
CMRT Consequence Management Response Team
CONOPS concept of operations
CRAF Civil Reserve Air Fleet
CRCPD Conference of Radiation Control Program Directors
CRI Cities Readiness Initiative
CST Civil Support Team
DC District of Columbia
DHS Department of Homeland Security
DMAT Disaster Medical Assistance Team (NDMS)
DoD Department of Defense
DOE Department of Energy
OCR for page R18
Assessing Medical Preparedness to Respond to a Terrorist Nuclear Event: Workshop Report
DRC Disaster Resource Center
DTPA diethylenetriamine pentaacetic acid
ED emergency department
EMAC Emergency Management Assistance Compact
EMEDS Expeditionary Medical Support
EMP electromagnetic pulse
EMS emergency medical services
EMT emergency medical technician
EPA Environmental Protection Agency
ESAR-VHP Emergency System for Advance Registration of Volunteer Health Professionals
ESF-6 Emergency Support Function #6 (NRF)
ESF-8 Emergency Support Function #8 (NRF)
EUA Emergency Use Authorization
FCC federal coordinating center (NDMS)
FDA Food and Drug Administration
FEMA Federal Emergency Management Agency
FRMAC Federal Radiological Monitoring and Assessment Center
FY fiscal year
GPS global positioning system
Gy gray
hazmat hazardous materials
HHS Department of Health and Human Services
HPP Hospital Preparedness Program
HSI Homeland Security Institute
ICU intensive care unit
IND improvised nuclear device
IOM Institute of Medicine
IRB institutional review board
JumpSTART Simple Triage and Rapid Treatment (pediatric)
KI potassium iodide
kt kiloton(s)
LACDPH Los Angeles County Department of Public Health
mGy milligray
OCR for page R19
Assessing Medical Preparedness to Respond to a Terrorist Nuclear Event: Workshop Report
MMRS Metropolitan Medical Response System
mph miles per hour
MRC Medical Reserve Corps
mSv millisievert
NDMS National Disaster Medical System
NIH National Institutes of Health
NRAT Nuclear/Radiological Advisory Team
NRC Nuclear Regulatory Commission
NRF National Response Framework
NVHA Northern Virginia Hospital Alliance
NYCDOH New York City Department of Health and Mental Hygiene
NYSDOH New York State Department of Health
OSHA Occupational Safety and Health Administration
PAG protective action guide
PAG Manual Manual of Protective Action Guides and Protective Actions for Nuclear Events (EPA, 1992)
PF protection factor
PHEP Public Health Emergency Preparedness
P.L. Public Law
PPE personal protective equipment
psi pounds per square inch
PTSD posttraumatic stress disorder
QF quality factor
R&D research and development
rad radiation absorbed dose
RAP Radiological Assistance Program
RDD radiological dispersal device
RDF rapid deployment force
REAC/TS Radiation Emergency Assistance Center/Training Site rem roentgen equivalent man
REMM Radiation Event Medical Management
RHCC regional healthcare coordinating center (Northern Virginia)
RITN Radiation Injury Treatment Network
RSS receipt, stage, and storage (site) (SNS)
RTR Radiation Treatment, Triage, and Transport (system)
SFDPH San Francisco Department of Public Health
OCR for page R20
Assessing Medical Preparedness to Respond to a Terrorist Nuclear Event: Workshop Report
SI Système International d’Unités (International System of Units)
SNS Strategic National Stockpile
SRT Search Response Team
START Simple Triage and Rapid Treatment (adult)
Sv sievert
TOPOFF Top Officials
UASI Urban Area Security Initiative
U.S. United States
USPS United States Postal Service
VA Department of Veterans Affairs
WMD weapon of mass destruction
WMD-CST Weapons of Mass Destruction Civil Support Team
Items in cart [0]
