Reportontoxicgasattacksinthesuburbsof

IdlibandHama

Chemical,Biological,RadiologicalandNuclearTaskForce
(CBRNTF)

Reportedby:FieldandInternalCoordinationOffice,CBRNTF
ReportDraftedon:May4
th
2014

Introduction:
In Hama, Idleb, and other areas held by opposition forces the media and local health departments
report unusual toxic gas attacks in contested neighborhoods. A team has started investigating these
attacks,speakingwithphysiciansandinjuredvictimstoascertaintheveracityoftheseaccusations.

TheInvestigationProcess:
The Investigation team conducted field visits to Medical Facility A, Medical Facility B, the
Field Hospital in the northern suburbs of Hama (Kafrzeta), and the Alsiddiq hospital at Talmins
intheIdlebsuburbs.
Theteamconductedvideointerviewswithphysiciansandparamedics.Theteamalso
interviewedinjuredvictims,theirrelatives,andotherresidentsofneighborhoodsexposedtothe
toxicgasattacks.
Afterobtainingthehospitaladministration'sconsent,theteamreceivedphotocopiesofthe
injuredvictim'smedicalreportsandotherdocumentation.
Everyintervieweewasfullywarnedaboutthepossiblerisksofhis/herparticipationinthe
investigation.Theteamobtainedtheformalconsentofeveryparticipantthathis/hertestimony
wouldbeusedintheinvestigation.
InvestigationReport:
Theinvestigativeteamfoundthefollowing:
The village of Kafrzeta, in the northern suburbs of Hama, was exposed to a series of four
attacksinoneweek:
April11
th
2014:Anattackoccurredat18:00targetingthewesternneighborhoodofthevillage,
whichismostlyinhabitedbyinternallydisplacedpeople.Acontaineroftoxicsubstanceswas
firedatfourcivilianhouses.
MedicalReport:170peoplewereinjuredintheattack.Mostoftheinjuredweredischarged
laterthatday.Sevenvictimswereseriouslywounded,withthreeofthemdevelopingnon
cardiaclungedema.

Threeindividualswerekilledasaresultoftheattack:
MarwaMostafaAlmohammad,25yearsold,died4daysaftertheattack.
MostafaAlmohammad,70yearsold,diedafterintubationonthesamedayoftheattack.
Unknownfemalechild,diedinfieldoftheattackbeforeshecouldbetakentothehospital.

Symptoms: extensive cough, dyspnea, difficulty breathing, headache, hypotension, nausea,

vomiting, muscle spasms, fatigue and tiredness. There was also irritation and redness in
eyes,skin,andmucousmembranes.
Pupilsreflexwasnormaltherewasnolossofconsciousnessorseizures.
Treatment mainly included Oxygen, bronchodilator nebulizers, and IV fluids. We also
antiemetics,antibiotics,andcorticosteroidsattimes.

Field Report:The helicopter threw a large container that soundlessly exploded, releasing
unusual yellow orange color smoke, spreading a smell that is similar to detergents across
500 meters radius. The team visited the location and evaluated and measured the dimensions
ofthecratercausedbytheattack.

April12
th
2014:Anotherattackhitthedowntownofthecity.Wecouldnotdeterminethetime
oftheattack.
Medical Report:The medical report shows the reccurrence of the same symptoms and signs
of the previously mentioned attack. Twentyfive injured patients were evaluated. No deaths
werereported.Thecasesweretreatedsimilarlyasbefore.

FieldReport:
Thehelicopterthrewabigcontainerthatdidnotexplode,butreleasedanextremelyirritatingsmell
similartothepreviousattack.Wecouldaccessandexaminetheunexplodedcontainer:itis157cm
lengthand40cmdiameter.Embeddedonthetopithasthesymbol"CL2,"withotherphrasesindicating
thesizeandpressureofthecontainer.Theteamvisitedthelocation,evaluatedit,andmeasuredthe
dimensionsofthecratercausedbytheattack.

April14
th
2014:Thetimeoftheattackcouldnotbedetermined.TheattacktargetedZor
Alhesa,southofKfarzeta,anareathathadneverbeenshelledpreviously.
Medical Report:We detected five cases of injury, with no deaths. The injured patients had
samesymptoms,signs,andtreatmentplansasvictimsofthepreviousattacks.

FieldReport:Wecouldnotreachthetargetedlocation.

April18
th
2014:Afieldhospitalintheareawasattacked.
Medical Report:100 people were injured in the attack, although none were killed. All had
same symptoms, signs, and treatment plan as the prior attacks. Nine nurses (7 female and
male) were critically injured. One of the patients had extensive symptoms of hyper secretions
withoutpupilcontractionorseizures.

Field Report:Two canisters were dropped on the area, neither of which caused an explosion.
Theyreleasedanextremelyirritatingsmellwhichcausedthepreviouslymentionedsymptoms.

Note: The names and information of all injured victims are reported in a separate attached
file.

ThevillageofTalmins,inthesuburbsofIdleb,wasattackedbyanunusualtoxicgasonApril
21
st
2014.Theinjuredweretransferredandmanagedatfourhealthcenters:Alsiddiqfield
hospital,Jarjanazfieldhospital,MedicalFacilityA,andMedicalFacilityBattheSyrianTurkish
border.
FieldReport:Areainhabitantsandtheinjuredvictimsreportedahelicopterwasflyingoverthearea
whenitthrewtwobigcontainersat11:45am.Oneofthecontainersfellonahouse'sbackyardwithout
exploding,releasinganirritatingsmell.Thesecondcontainerhitahouseandexplodedabout100meters
fromthefirstcontainer.Itdamagedtheroomsofthehouseandcausedadensecloudofgreenyellow
smoke.

The monitoring station reported the helicopter route as follows:Departure 10:30am en route
toHama=>Souran=>Skek=>AboMakki=>Jarjanaz=>Talmins.

The container carrying the toxic substance was 180 cm length, and 90 cm diameter.The field
investigation encountered a strong irritating smell in the area that required team members
put protective cloths and masks to protect their airways. It was also reported a number
dead animals in the area, especially birds and cattle. Trees also turned yellow in the areas
thetwoattacks.
Thetwoholescausedbytheattacksweremeasuredandtheareaswereexamined.
Witnesses reported that there was a strong West to East wind on the day of the attack, which
allowedthecontaminationtospreadabout2KM.Thetemperaturethatdaywas2025C.

MedicalReport:
Alsiddiqfieldhospital,Talminsvillage:
Followinganexplosion,theAlsiddiqfieldhospitalinthevillageofTalminsreceived
approximately250injuredpatients.Another100casesweretransferredtoJarjanazfield
hospital,and19caseswentontoSaraqebhospitalforadvancedcare.

One of the doctors working at Alsiddiq field hospital mentioned that patients arrived to
hospital from the attack area with the following symptoms: irritation, seizure (one case),
vomiting, bluish, redness of the skin with itching, redness of the eyes, hyper secretion of saliva,
dyspnea, pupil contraction, epiphora, cough, abdominal pain, difficulty breathing and loss
consciousness.
Thehospitalstreatedthepatientsinthefollowingmanner:
o Removingthepatients'clothesandcleaningthecontamination
o Respiratorysupportwithoxygen,bronchodilators,frequentaspirationofsecretions,and
intubationiftheO2saturationwaslessthan80%.
o IVfluids
o Allergymanagementwithsystemiccorticosteroidsandintradermaladrenaline.
o Symptomaticmedicationslikeantiemetic,antiseizures,Atropine.
The doctor also reported that staff evacuating the patients to the hospital demonstrated
symptomsofcontaminationsuchaseyeandskinirritation.AllHospitalstaffwereunharmed.
The last case was received two hours after the attack. Some of the injured were located
approximately two kilometers away from the attack site. Patients were still following up
thehospitaluntilthetimeofthedoctor'stestimony(30hoursaftertheincident).
MedicalFacilityA,Idlib:
At 12:00 pm, the hospital received a warning of an unusual toxic gas attack. The hospital
immediately made arrangements for their own protection. The hospital received 19 cases
asphyxia.Thefirst10patientswerearrivedtogether(4womenand6children).
One of the doctors and three nurses reported their testimony to the investigation team. They
reported that when the ambulance arrived, there was an irritating smell so they took further
protective arrangements. The patients' symptoms included dyspnea, coughing, difficulty
breathing,nausea,vomiting,itchingandrednessoftheskin.
Therewerenoseizures,pupilcontraction,bradycardia,ormusclespasms.

Managingthecasesincluded:
o Removingthepatients'clothesandcleaningthecontamination.
o Respiratorysupportwithoxygen,bronchodilators,frequentaspirationofsecretions,and
intubationiftheO2saturationwaslessthan80%.
o IVfluids
o Allergymanagementwithsystemiccorticosteroidsandintradermaladrenaline.
o Symptomaticmedicationslikeantiemetic,antiseizures,Atropine.
A chest XRay was performed on the patients, which showed nonspecific consolidations
thelungareas.
Thirteen of the patients were discharged eight hours after their arrival and asked to follow
with the hospital if any respiratory symptoms reoccurred. The other six cases were
transferredtoMedicalFacilityBattheSyrianTurkishborder.
MedicalFacililtyB,Idlib:
At 01:30 pm, the hospital admitted five patients exposed to unusual gas attacks. Around 7:00
pm,thehospitalreceivedtwoadditionalcasessufferingfromsimilarsymptoms.

Thetreatingdoctorsentafullreportwithaclinicalpresentationofthecases:
Firstcase:
Mohammad AbdulRazzak Alhashash, 6yearold male, arrived the hospital at 1:30 pm.
was getting prepared to go to school when he was exposed to a yellow toxic gas. He was
unable to breathe and lost consciousness. The patient arrived at the hospital intubated under
mechanical ventilation both his heartbeat and breathing were stopped. CPR was performed
andallattemptstorevivehimfailed.
Clinical symptoms upon arrival included: redness in the face, pink foamy secretions,
dilation,diffusedcracklesinbothlungsareas.
Thepatientdiedat2:00pmofApril21
st
2014.

SecondCase:
Khadejah Barakat, a 65yearold female, arrived at the hospital at 2:30 pm. She was at home
when the toxic material container hit. Yellow gas started to spread and she experienced
difficultybreathingandasphyxia.
Clinical presentation upon arrival: patient was awake, oriented, with symptoms of dyspnea,
tachycardia, sweating, irritation, extensive cough, crackles in both lungs areas, O2 saturation
of70%.
By 2:40 pm the patient was intubated and put under mechanical ventilation with aspiration.
Hersecretionswerefoamyandextensive.
Her oxygen saturation declined to 60%. At 7:00 am on April 22
nd
2014, the patient was
transferredtoTurkeyforadvancedmedicalcare.

Thirdcase:
Marwa Hashash, 15yearold female, arrived hospital at 7:00 pm. She was at home when
toxic material container hit, yellow gas started to spread and she experienced difficulty
breathingandasphyxia.
Clinical presentation upon arrival: patient was awake, oriented, with symptoms of dyspnea,
tachycardia, sweating, irritation, extensive coughing, crackles in both lungs areas,
saturationof60%.
ShewastransferredtoTurkeyforadvancedmedicalcareat7:00amofApril22
nd
2014.

Fourthcase:
Ahmad Barakat, a 64yearold male, arrived hospital at 2:30 pm. He was at home when the
toxic material container hit, yellow gas started to spread and he experienced difficulty
breathingandasphyxia.
Clinical presentation upon arrival: patient was awake, oriented, with symptoms of dyspnea,
tachycardia, sweating, irritation, extensive cough, crackles in both lungs areas, O2 saturation
of80%onroomair.O2saturationincreasedto90%withtheoxygenmask.
The patient was observed for 48 hours. By managing with bronchodilators and oxygen,
saturation improved to 95%. The patient was discharged from the hospital on April 23
2014afterperformingthisCXR:

The patient reported his testimony about the attack and his injury, and it matched all the other
testimoniespreviouslymentioned.

Fifthcase:
MarioumehAlhashash,a19yearoldfemale,arrivedhospitalat2:30pm.Shewasathome
whenthetoxicmaterialcontainerhit,yellowgasstartedtospreadandsheexperienced
difficultybreathingandasphyxia.
Clinical presentation upon arrival: patient was unconscious, with symptoms of dyspnea,
tachycardia, sweating, irritation, extensive cough, crackles in both lungs areas, O2 saturation
of45%.
The patient was intubated and put under mechanical ventilation with aspiration of secretions,
whichwerefoamyandextensive.
Afterobservationonmechanicalventilationfor72hours,O2saturationdidnotsurpass92%.
The patient was transferred to ICU and died on April 25
th
2014 of respiratory deterioration
andnoncardiaclungedema.Thefollowingpicturesdepictthepatient'ssituationand

CXR24hoursaftertheattack.(ThefirstnameontheXRayisinaccuratebymistake).

Caption:CXR,48hoursaftertheattack.(ThefirstnameontheXRayisinaccuratebymistake).

Sixthcase:
Sanaa Alakhras, a 30yearold female, arrived hospital at 2:30 pm. She was at home when
the toxic material container hit, yellow gas started to spread and she experienced difficulty
breathingandasphyxia.
Clinical presentation upon arrival: patient was awake, oriented, with symptoms of dyspnea,
tachycardia, sweating, irritation, extensive cough, frequent vomiting, abdominal
heartburn,O2saturationof80%onroomair.Itincreasedto92%withtheoxygenmask.
By managing the patient and observation for 24 hours in the ICU, O2 saturation dropped
83%. She was intubated and put under mechanical ventilation with aspiration of secretions,
whichwerepink,foamy,andextensive.
The patient was 6 months pregnant at the time of the attack, which was confirmed by
GYN doctor. Additionally, She is the mother of the killed child "Mohammad Alhashash"
mentionedearlierinthisreport.

Thefollowingpicturesshowmoreaboutthepatient'ssituation:

CXR,24hoursaftertheattack:

CXR,48hoursaftertheattack:

Thepatientregainedconsciousnessandwasremovedfrommechanicalventilation.Shereportedher
testimonyabouttheattackandherinjury.

Seventhcase:
Miada Alhashash, a 50yearold female, arrived at the hospital at 7:00 pm. She was at home
when the toxic material container hit, yellow gas started to spread, and she experienced
difficultybreathingandasphyxia.
Clinical presentation upon arrival: patient was awake, oriented, with symptoms of dyspnea,
tachycardia,sweating,irritation,headache,O2saturationof88%onroomair.
She later developed crackles in both lung areas with bluish extremities, O2 saturation reduced
to70%by7:35pm.
The patient was intubated and put under mechanical ventilation with aspiration of secretions,
whichwerepinky,foamy,andextensive.ShewastransferredtotheICU.

CXR,24hoursaftertheattack.(ThelastnameontheXRayisinaccuratebymistake):

CXR,48hoursaftertheattack.(ThefirstnameontheXRayisinaccuratebymistake):

Conclusion
All eyewitnesses' testimonies reported by physicians, injured victims, and inhabitants of the attacked
areasreportthefollowing:
Symptomsandsignsthatwererepeatedinallcases:dyspnea,coughing,eyeandskinirritation.
Somecasesexperiencedpupilcontractionandseizures.Nosymptomsofskinburnsor
blisteringwerereported.
KafzetaandTalminsweremostlikelyexposedtoanunidentifiedtoxicgasattack.
TheattacksthattookplaceduringtheperiodofApril11
th
April21
st
caused5deathsand
approximately1,000injuriesofvaryingseverity.
Accordingtohospitalreports,3%ofcasesadmittedtothehospitalrequiredadmissionto
intensivecareunits.Additionally,7%ofthecasesrequiredhospitalizationofmorethan24
hours.
AccordingtotheAlsiddiqhospital,53%ofthevictimsoftheTalminsattackwerechildren
under18yearsold.

AboutSAMS:
TheSyrianAmericanMedicalSociety(SAMS)isindependent,nonprofit,professional,
medicalandhumanitarianorganizationthatrepresentsmedicalprofessionalsofSyrian
descent.ThroughitsrichnetworkwithintheUSandinSyria,SAMSorganizesannualmedical
missionstoSyria,providesprofessionalandeducationalprogramstoSyrianphysiciansand
organizesdonationsofmedicineandmedicalsuppliestolocalhospitalsandunderprivileged
familiesinSyriaandNorthAmerica.