Poison Gas The Moscow Theater Crisis
Did the Russians government’s unusual response to the crisis help or hurt the hostages? We will also touch on what these events from twenty years ago have to do with today’s very current drug epidemic. Want to know what links these two seemingly disparate things? Stay tuned to find out.
This is the Pick Your Poison podcast. I’m your host Dr. JP and I’m here to share my passion for poisons in this interactive show. This is the first historical episode, looking back at riveting, and often harrowing, stories of poisoning from the past.
Today we’ll discuss the Moscow Theater Crisis and what happened when Chechen rebels held Russian theatergoers hostage. Did the Russians government’s unusual response to the crisis help or hurt the hostages? We will also touch on what these events from twenty years ago have to do with today’s very current drug epidemic. Want to know what links these two seemingly disparate things? Stay tuned to find out.
If you’ve listened to other episodes, you know I use fictional patients, based on real cases, to illustrate the symptoms of different poisons and toxins. However, in this historical episode we’ll discuss real events that actually occurred.
The incident started October 23, 2002 in Moscow at a theater named the House of Culture of State Ball-Bearing Plant Number 1. During the second act of a play, 40 to 50 gunmen entered the theater. Several patrons initially mistook the gunfire for part of the performance. The gunmen were masked and clad in all black. Many had bombs and explosives strapped to their bodies. The Chechens took the 850 to 900 people inside the theater hostage.
A little background here for context before we go any further. The Russia-Chechen conflict began after the fall of the Soviet Union in 1991 when Chechnya declared itself independent. The hostilities included two wars, the siege of Grozny, Chechnya’s capital city, and ended without independence for Chechnya. In 2009, Russia declared the war over, though intermittent clashes, and terrorist attacks continued.
From the theater, the Chechen rebels demanded immediate withdrawal of Russian forces from Chechnya, giving a deadline of one week. If Russia didn’t comply within that time, the terrorists would begin killing hostages. Most of the hostages were Russian, though some were foreign nationals. There were also children present.
Russian forces quickly surrounded the theater, lightning the area with spotlights trained on the building. The rebels responded by promising to kill ten hostages for every Chechen harmed. During the first two days of the siege a small number of hostages were released including some children, pregnant women, and Muslims. There are conflicting reports about the treatment inside, some sources saying that the hostages were denied water and others saying that they were given only water and chocolate to eat. The orchestra pit was used as a lavatory.
Several hostages were killed when a man tried to escape. The Chechens identified themselves as a suicide squad, saying they were all willing to die for their cause as they all had lost family members in the war and therefore had nothing to lose.
The toxicology part of the story, and what’s made this particular incident so famous, began on Day 4. In the early morning, at 5am, on October 26. At this point, the standoff had been going on for fifty-seven hours. Outside the theater, the spotlights suddenly went dark.
The Chechens had said if the lights went out, they would assume the Russian security forces were attacking and react accordingly. Instantaneously, smoke began to billow through the building, coming from the ventilation system, from holes in the walls, and from underneath the stage. Hostages assumed there was a fire.
It quickly became clear there was no fire, and this wasn’t smoke.
Inside the theater, people fell unconscious. Both hostages and Chechens.
Thirty minutes later, Russian spetsnaz special forces stormed the building. Not everyone inside was unconscious. Some of the Chechens reportedly had gas masks. After an hour of gunfighting, the Russians burst into the main hall.
Exactly what happened during this time and in the time immediately following the assault is a matter of debate, for reasons which I’ll discuss in a bit. Photos from news media clearly show bodies, laid in rows on the sidewalk outside. A journalist on scene reported the faces of the hostages “waxy, white and drawn. Their eyes were open and blank.” Some of these people were dead, some unconscious. The bodies were subsequently piled haphazardly into buses.
The “smoke” instead the theater was definitely poison gas, released by the Russians. Other than this fact, specific details are not clear, even today. Initially, the Russians reported using an “anesthetic gas” released into the air-conditioning ventilation system. This sparked debate and speculation around the world about what exactly was in the gas.
At the same time, there was much misinformation, and again speculation, about what happened to the hostages. The Russian’s first report said all the rebels had been killed and all the hostages survived. Sadly, this was not the case.
Physicians were among the few able or allowed to speak to journalists. Doctors at local hospitals stated that they were prepared to receive patients with wounds from bullets or explosions. They had not been warned to expect unconscious patients with exposure to unknown toxins.
To this day, the exact number killed by the gas is not known. At least a hundred and thirty hostages were killed including, tragically, twenty-five children. In addition, 40-50 Chechens died. Some from the gas, others were shot. In total, it’s believed at least two hundred lives were lost inside the theater.
Speculation about the ingredients in the poison gas continued to swirl worldwide. Four days after the gas release, on Oct 30, the Russian Health Minister identified it in a news conference.
Bringing us to question number one in today’s interactive podcast. What specific agent did the Russians report was used to incapacitate the Chechens and the victims?
Halothane (an anesthetic gas)
Diazepam (Valium)
Fentanyl
BZ gas
Answer C. Fentanyl.
The Russian government doesn’t have a reputation for, shall we say, honesty and transparency. For example, they initial reported all the hostages survived. This despite photos of bodies lying on the sidewalk and stacked in buses. So, can we believe what they said about the gas composition? Was it really fentanyl?
As I mentioned, the entire world was speculating. Guesses included all of the other answers. Halothane is a classic anesthetic gas. It’s fallen out of favor due to its side effects but it was used in the operating room for decades. Benzodiazepines are sedatives, like Valium, Xanax or Ativan. There’s no evidence they were used in the theater. BZ is a gas once stockpiled by the US military for use as an incapacitating agent. It’s an anticholinergic meaning it causes delirium and hallucinations. There was no evidence for this either.
Let’s come back to this question in a minute, and ask first if fentanyl fits with the victims’ symptoms. Fentanyl is a powerful opioid. Like morphine or heroin, but much more potent. Opioid overdoses cause a classic triad of symptoms. One, a depressed mental status, ranging from sleepy to unconscious. Two, depressed breathing, from slow to not breathing at all. Third meiosis, meaning small pupils.
Symptoms witnessed by bystanders and reported by survivors are consistent with exposure to an opioid gas. First it was fast acting, as fentanyl is. Once the gas was released, the victims fell unconscious very quickly. It also fits with the little we do know about the deaths. Reports say hostages suffocated when their heads fell forward, closing off their airways, or from lying prone on their backs, and gruesomely, choking on their tongues.
If you know anything about opioids in general, and fentanyl in particular, you know there’s an antidote. Question number two. What is the antidote for fentanyl and other opioid overdoses?
Naloxone (Narcan)
Flumazenil (Romazicon)
Charcoal
Physostigmine (Antilirium)
Answer: A naloxone (Brand name Narcan).
Naloxone is the antidote for opioid overdoses. Years ago, during my residency, it was used only by healthcare providers, doctors, nurses, medics, etc. Because of the opioid crisis in the US, you might be familiar with it. You might even have had to administer it to someone yourself. Naloxone is safe and effective. So much so, that the FDA just approved it for over-the-counter use.
Question #3. How can naloxone be given?
Intranasally
Intravenously
Intramuscularly
Subcutaneously
All of the above.
Answer: E all of the above.
It can be squirted intranasally, into the nose, this is the form that’s been approved for over-the-counter use. It can be injected intramuscularly like into the arm or the thigh, substantially under the skin, or given intravenously. Often, one or two doses are all you need to reverse an overdose.
So, getting back to the Moscow Theater Crisis, was this fentanyl? If it was then why did hundreds of people die from a toxin with an antidote? A well-know, safe antidote? Good question. One asked by toxicologists and many others in the aftermath of the crisis.
Once again, the details are obscured. The FSB, or the Federal Securities Service of Russia, successor to the KGB, prevented survivors from speaking out or speaking to journalists. The Russians said the top-secret nature of their assault was necessary for security reasons. The Russian Secretary of Health add that specialists were informed and warned about a gas attack and that more than a thousand doses of antidote were prepared.
In interviews with Russian physicians, they insisted they received little or no notice of a gas attack and said supplies of naloxone were either absent or in short supply. Additionally, doctors were told to write in charts that patients were the victims of terrorism and violence, rather than victims of poisoning or gas exposure.
Doctors working on that day said busloads of dead and unconscious patients arrived at the hospital. One thirteen-year-old girl still alive after leaving the theater, died on the way to the hospital, buried underneath dead bodies. Doctors were even prevented from releasing healthy patients from the hospital for several days, presumably to control information related to the attack. The Russians tried to blame all the fatalities on the Chechens.
Back to the gas ingredients. Remember the Russians initially said it was an anesthetic gas, then said it was fentanyl. Do we believe them?
One study examined German survivors, finding halothane in their blood and urine. So, if you answered A. Halothane on question 1 you might be correct. Halothane has a distinctive smell, not reported by the hostages. It also takes longer to work than what was used. And once halothane gas is turned off, patients wake up and return to consciousness almost immediately, which is one of the reasons it’s used in the operating room.
Footage clearly shows victims remained unconscious despite fresh air outside the theater. Meaning they didn’t wait up after removal from the exposure. The conclusion is that halothane may have been part of the mixture but wasn’t the primary component. The German study didn’t find fentanyl or derivatives. But they noted those drugs would’ve been metabolized, broken down, by the time the blood and urine specimens were obtained.
The British also studied this. They took a different route, analyzing clothing samples. They found the presence of remifentanil and carfentanil on clothing from two survivors. A metabolite of carfentanil was found in a third survivor’s urine. Remifentanil is used for surgery in some countries. Carfentanil is used by veterinarians as a sedative for large animals like elephants, rhinoceroses and hippos. It’s not still commercially available in the US, but was sold under the brand name Wildnil. Carfentanil is 10,000 times more potent than morphine and 100 times more potent than fentanyl.
To this day, we don’t know the exact composition of the gas. The generally accepted conclusion is that it was a combination of substances including halothane and several fentanyl derivatives.
This brings us to the end of our discussion, but leaves us with one big unanswered question. Did the Russian’s use of the gas ultimately help or hurt more hostages?
Only you can answer this one. No one knows the right answer.
They justified their use of the poison saying more hostages would’ve died if they hadn’t used it. They believed the Chechens would’ve killed all 800 or 900 hostages. The Chechens did kill several hostages and had explosive strapped to their bodies. Chechen terrorists used lethal force in attacks on Russia both before and after the theater crisis. In 2004, Chechen rebels attacked a school. Three hundred and thirty-three hostages died, including hundred and eighty-six children.
World reaction was mixed. The US and UK governments agreed with the Russian assessment that more would’ve died had the poison gas not been released. However, the Russians were strongly criticized for not having naloxone on scene and for not advising physicians as to the nature of the poison gas. Others, including the European Court of Human Rights, found the hostages rights had been violated and hold Russia accountable their deaths. Many believe the crisis and response solidified Putin’s authoritarian position.
There are strong opinions and valid arguments on both sides. It's a difficult and thought-provoking question. Approximately, 16% of the hostages died and 84% survived. Could it have been less than 1% that lost their lives? Or 100% fatalities? Ultimately, we will never know if more lives were saved or ended by the use of the opioid gas in the Moscow theater terrorist attack.
I started on this episode to talk about these unusual events that occurred over twenty years ago. Fentanyl is in fact an extremely timely topic, more relevant now than ever. Listen to Episode 6, really part II of this episode for more. We’ll discuss which opioid is killing Americans at a horrifying rate. We’ll also cover drug adulteration, including Tranq or Tranq dope which is currently receiving a lot of news coverage.
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