Talk:Alleged Chemical Attack, March 16, 2015

Video

 * Playlist: Sarmin CW attack

Breaking!
New report from Sermin Idlib ( ادلب:سرمين )

"Civil Defense Idlib: Srmin: a very important three children and their parents and their grandmother chemical gas victims"

Family of Five

Some water (alkalai?) decontamination and gas masks but several don't wear gloves and the woman's clothing seems original. -- ‎Charles Wood


 * Incredibly sad. It seems the one toddler, red-haired FWIW, dies right there and no one really cares. You get the common feeling "Assad" targeted people the rebels don't really like. Though they didn't specifically blame anyone there. I don't suppose there's much more info available at the moment (checked VDC martyrs database, nothing relevant yet). --Caustic Logic (talk) 10:32, 17 March 2015 (UTC)


 * The couch that talks has already determined it was conclusively 'Assad Gas'. But he would say that, wouldn't he? -- ‎Charles Wood


 * Urs is on the case and has collected videos since they started uploading. The brown-nosed one isn't the only known propagandist involved with this. One Hadi Al Abdallah with a long history of "rebel" propaganda is even trolling John Kerry on twitter. She thinks that reveals the motive, and is convinced that the "rebels" did it for propaganda reasons - pointing out the usual treatment of the dead "like meat". But she would say that, wouldn't she? ;o) --CE (talk) 14:25, 17 March 2015 (UTC)

More details, names, symptoms etc. 'Warplanes attacked'. One mention of Chlorine but symptoms don't match at all. Scene looks like standard Sarin treatment Facebook Page --Charles Wood (talk) 10:55, 17 March 2015 (UTC)


 * This video needs the sort of detailed analysis that someone like Denis would be able to do. From a quick look, I agree with Urs that these aren't real medics/paramedics.  These children, if they were still breathing or had only just stopped breathing, needed immediate respiratory support via an endotracheal tube or just mouth-to-mouth. The red-haired boy is left on the trolley until he stops breathing, then someone makes a desultory effort at suction which is pointless without respiratory support.  The other two children are placed on top of the woman on the trolley in positions where they can't be resuscitated - better to put them on the floor.  One child is held up by the lower jaw for no obvious reason, with a grip that appears to compress both carotid arteries.  All three children appear cyanosed - these aren't like the children in the Kafr Batna sun morgue who were pink.  My impression is that these children have been given an overdose of some powerful respiratory / central nervous system depressant like morphine. Pmr9 (talk) 16:33, 17 March 2015 (UTC)


 * I think we can rule out not just chlorine but any agent that is not a central nervous system depressant - otherwise the red-haired boy would be struggling to breathe. Opiate poisoning is the most likely diagnosis because most other sedative drugs don't cause this degree of respiratory depression without causing coma. On a frame-by-frame view, it looks as if this child has dilated pupils.  Most opiates including morphine cause pinpoint pupils in overdose.  The only one that causes dilated pupils is meperidine (Demerol), still widely used as a painkiller.  Pmr9 (talk) 17:48, 19 March 2015 (UTC)
 * Thanks for your expertise here. If it can be narrowed down like that, we can get somewhere. Some unit might be asking for more Demerol soon, or they had a huge supply to begin with. --Caustic Logic (talk) 22:57, 19 March 2015 (UTC)
 * Meperidine was a standard battlefield analgesic for the US military at least until the 1970s, but is now rarely used in the US and Europe because of its central nervous system toxicity. From a scan of recent publications, it's still widely used in Turkish military hospitals and is manufactured in Turkey under the brand name Aldolan. Pmr9 (talk) 13:00, 20 March 2015 (UTC)

Denis!
(header by Adam) --Caustic Logic (talk) 00:13, 22 March 2015 (UTC)

Denis O'Brien here. Perhaps I could add some observations/thoughts to this Sarmin attack. ..
 * A. The videos I have studied are vids 1/2/4/6/8 in Pmr9’s playlist – these are the ones showing clinic shots.  I use his numbers here.  Vids 1 & 2 show a distinct clinic – or clinic rooms – from the clinic in vids 4/6/8.  The main reason I say this is that the floors are different – terra cotta in vids 1 & 2 and tile pattern in vids 4/6/8.


 * B. The two clinics are connected by at least one person common to both – that is an older gentleman with a knit cap and glasses.  He is seen at 1:02 in vid O1 and a number of times in vid 06.  I refer to him as “P2.”  I haven’t taken the time for side-by-side comparisons of the vids, but this guy is the only one that stands out as being in both of the clinics.


 * C. Vids 1&2 show a woman medic, whom I call “P1.”  She seems to be in charge.  She is wearing full scrubs and a sweater w/ grey/black horizontal stripes.  She is not wearing a hijab.  I don’t see any women in vids 4/6/8 – victims or personnel.


 * D. The Sarmin videos strike me as being quite different from the Ghouta vids b/c in the Sarmin vids the workers’ faces are featured and some of the workers are interviewed with their faces uncovered.  In the Ghouta vids, seeing the workers’ faces was very rare.  (Vids 1&2 are more like the Ghouta vids in this respect -- no faces -- than vids 4/6/8.)  Also, there were no naked children in the Ghouta vids – or if there were, they weren’t featured – but vids 1&2 focus on the three naked kids, which may suggest the Sarmin vids were not staged whereas the Ghouta vids were.


 * E. Here are some observations on the 4 victims seen in vids 1&2. I identify these victims as follows – vid times w/ respect to Vid 01.  Infant boy (N1) seen at 0:01.  Infant girl (N2) seen at 0:30.  Infant girl ? (N3) in diapers, seen at 1:16.  Adult woman (A1).


 * Infant N1 is alive at the beginning of vid 01 but appears to be dead by the end of vid 02, establishing the sequence of the two vids. N1 is the only one of the four kids that is unequivocally alive.  His respiration is grossly depressed, but can be confirmed by closely watching the nasal mucus in vid 02.  His color is poor; his lips are mildly cyanotic.  He is clearly not struggling for air.  Like all three infants, his muscles are flaccid.  His skin is clear and without trauma or burns w/ the exception of a small brownish lesion on his R elbow.  If N1 was dying as a result of chlorine in his lungs, one would expect him to be very distressed, in pain, gasping for air, and – if the chlorine contacted his skin – showing skin redness or burns.
 * I don’t know why the guy is jabbing the needle into N1's chest and twisting it around – vid 02 at 1:07. A very rough intracardiac injection,I guess.  Looks like a clear fluid in the syringe – epinephrine?  Didn't work.
 * All 3 kids have clear skin. The color is fairly good, but lips are mildly cyanotic.  No blisters or lesions.  From the little of the eyes that can be seen, they are rheumy, not irritated – chlorine would make the eyes irritated, bloodshot.  Pupils can’t be read.  There is no clear indication of vomiting or defecation, although N3's diapers look like they’re full.  N1 (and only N1) is producing a small amount of nasal mucus.
 * What little can be seen of the woman, A1, is noteworthy. In vid 01 she is grimacing and her eyes are slightly open and rheumy.  In vid 02 she is expressionless and her eyes are closed. Her color looks pretty good in vid 02 – 1:25.
 * At 0:15 in vid 01 you can see her R hand behind the head of N1. The hand has a brownish stain on the palm.  Splotches of the same color are seen on the sheet behind N3 – vid 02 at 1:30.  Also, at the end of vid 02, there is a brown stain the same color over the L eye of N1.
 * There is no rigor in any of the kids. The skin color is not yet developing palor mortis or livor mortis.  A view of the 3 children in their funeral wraps is here:  https://www.youtube.com/watch?v=JIlBRb2aFzo&feature=youtu.be


 * Impressions of the clinics.
 * Well funded and well equipped.
 * Clean sheets/blankets. The yellow/black blankets look like they were custom made with the logo.
 * De-fibrillator in vid 01 is turned on. Looks like quite a bit of gear.
 * Lots of O2 bottles, but O2 is not administered to N1.
 * Most of the people are milling around not doing anything helpful, as in Kafr Batna. There are a lot of people taking photos/vids, and you can easily see their faces, unlike Kafr Batna.
 * Unlike KB, no guns & no military uniforms.


 * I can’t see enough to take a stab at the cause of death, if there is, in fact, a single, common cause. It was not chlorine, almost certainly not sarin.  Not carbon monoxide or cyanide, as in Kafr Batna.  No trauma.


 * Pmr9 suggest Demerol (pithidine or meperidine) – could be. These opiates depress respiration by acting in the brain – i.e., suffocation w/out struggling.  Most opiates constrict the pupils, but not Demerol.  At the moment it’s as good as guess as any I can come up with.  What does it mean if these kids died of Demerol?  It would almost have to be injected.


 * I am on the road as I write this and 3000 miles from my shelf of pharmacology books, so without more research I’m not comfortable making a guess at what killed them. Jabhat al-Nusra, perhaps, if Kafr Batna is any indication, but it’s way to early to say.

Pierpont (talk) 22:38, 21 March 2015 (UTC)Pierpont


 * This is so much more awesome than we should expect, for on the road and short notice. You mention brown stains on the woman's hand - similar color (truama/bruise? too new to be brown? so stains?) on baby 1's right elbow as well as left brow. This is a clue of some kind. --Caustic Logic (talk) 00:13, 22 March 2015 (UTC)

"Pupils can’t be read." This is important, so I went to the second video, close-up on (that must be Mohammed) at 0:18. Managed to adjust gamma and contrast. left eye wasn't so helpful, so this is just the right. Iris seems gray, barely there. Still not super clear but maybe the best it gets. What do you think now? (or when you get a chance?) --Caustic Logic (talk) 23:48, 22 March 2015 (UTC)

Amnesty International
Amnesty "International" jumping on the band wagon in their usual style. --CE (talk) 23:08, 17 March 2015 (UTC)


 *  The injured included a small number of fighters from the Free Syrian Army armed group, but the vast majority were civilians. In the middle of jabhat al-Nusra territory - yeah right!


 * ANOTHER VIDEO from the clinic is linked here. Note the different video identification which has now switched to Nusra. There is some curious medical treatment in the video. ricksterling


 * Welcome, Rick. Indeed, a Nusra flag on this one. No switch in anything really implied of course, just a different cameraman with his affiliation. The chest compressions here seem comically overdone, besides being useless. Seems they want to be seen as really trying to help, in case reality let slip any signs of the opposite. --Caustic Logic (talk) 22:57, 19 March 2015 (UTC)


 * The release of the two videos doesn't seem to have been coordinated: viewed separately the lack of effective treatment might just be explained by a lack of training, but taken together they make it obvious that the resuscitation is staged: in video 1 there is a minimal attempt at rescuscitating the red-haired boy which is then abandoned. In video 2, they start resuscitation all over again on all three children.  We really should point this out to Amnesty and get them to retract their earlier statement Pmr9 (talk) 13:00, 20 March 2015 (UTC)


 * The video linked by Rick shows the dilated pupils more clearly though at this stage (at least 2 minutes after respiratory arrest) it's not a specific sign. This video appears to start immediately after the end of the first one.  It looks as if having left the children to be filmed lying on the trolley, they thought they'd better make a show of trying to resuscitate them.  The cardiac massage and intracardiac injection are pointless without artificial ventilation.  I think these videos are worth a detailed study along with others from the same source.  Linking them may give more clues to the identities of the perpetrators. Pmr9 (talk) 10:34, 20 March 2015 (UTC)


 * A doctor and a civil defence worker told Amnesty International those affected by the attack had no injuries associated with explosive weapons, but showed symptoms characteristic of a chemical weapons attack, including reddened eyes, shortness of breath, continuous coughing, respiratory distress, vomiting, and drooling from the mouth. Except the videos of the children only showed drooling on one of them and none of the other symptoms on any. --Charles Wood (talk) 00:50, 18 March 2015 (UTC)


 * I will point out that at least one of the infants has signs of trauma on one side of their head. This is not consistent with the Amnesty statement of no injuries associated with explosive weapons --Charles Wood (talk) 11:45, 20 March 2015 (UTC)

Chlorine Gassing Symptoms

 * ''See also Talk:Alleged Chemical Attack, August 21, 2013


 * "Medical Diseases of the War" by Arthur Hurst, M.A., MD (Oxon), FRCP.
 * The first effect of inhalation of chlorine is a burning pain in the throat and eyes, accompanied by a sensation of suffocation; pain, which may be severe, is felt in the chest, especially behind the sternum. Respiration becomes painful, rapid, and difficult ; coughing occurs, and the irritation of the eyes results in profuse lachrymation. Retching is common and may be followed by vomiting, which gives temporary relief. The lips and mouth are parched and the tongue is covered with a thick dry fur. Severe headache rapidly follows with a feeling of great weakness in the legs; if the patient gives way to this and lies down, he is likely to inhale still more chlorine, as the heavy gas is most concentrated near the ground. In severe poisoning unconsciousness follows; nothing more is known about the cases which prove fatal on the field within the first few hours of the "gassing," except that the face assumes a pale greenish yellow colour.


 * When a man lives long enough to be admitted into a clearing station, he is conscious, but restless; his face is violet red, and his ears and finger nails blue ; his expression strained and anxious as he gasps for breath; he tries to get relief by sitting up with his head thrown back, or he lies in an exhausted condition, sometimes on his side with his head over the edge of the stretcher in order to help the escape of fluid from the lungs. His skin is cold and his temperature subnormal; the pulse is full and rarely over 100. Respiration is jerky, shallow and rapid, the rate being often over 40 and sometimes even 80 a minute ; all the auxiliary muscles come into play, the chest being over-distended at the height of inspiration and, as in asthma, only slightly less distended in extreme expiration. Frequent and painful coughing occurs and some frothy sputum is brought up. The lungs are less resonant than normal, but not actually dull, and fine riles with occasional rhonchi and harsh but not bronchial breathing are heard, especially over the back and sides. Headache is generally severe, and there is also considerable epigastric discomfort, due partly to the strain of coughing and partly to gastric irritation, as it is increased if an attempt is made to eat.


 * The intense dyspncea of this asphyxial stage lasts about thirty-six hours, after which it gradually subsides, if death does not occur before. The patient, exhausted from his fight for breath, then falls asleep and wakes up feeling much relieved. A few hours later acute bronchitis or broncho-pneumonia develops. In severe cases the quiescent interval is short and the bronchitis very severe. The sputum is now viscid, yellow or greenish, and muco-purulent with occasional streaks of blood. Respiration becomes more shallow and rapid, and the rate may finally be even 70 or 80 a minute. The pulse is small and very rapid ; the temperature rises, and is often as high as 104. The patient may now become delirious. Pleurisy may occur, and in some instances empyema and gangrene of the lung have followed.


 * After recovery from the bronchitis and pneumonia the patient remains weak and exhausted for a considerable time. He gets tired very rapidly and is unable to walk quickly or up hill without getting short of breath, even after the last signs of bronchitis have disappeared. He may continue to have attacks of dyspncea and cyanosis for several weeks. The frightful experience he has passed through often affects his nervous system, and some of the attacks are doubtless aggravated by apprehension. Headache, vertigo and dyspepsia may continue for several weeks. --Charles Wood (talk) 01:00, 18 March 2015 (UTC)

Everybody including John Kerry and the US State Department is saying this was chlorine. Maybe it was. What I find most interesting is that the symptoms and the whole "operation" seem strikingly similar to the Ghouta CW attack. We and others should compare the footage and note the similarities and differences, if any. -- Petri Krohn (talk) 11:31, 20 March 2015 (UTC)

Meperidine Symptoms
Meperidine because it likely wasn't brand-name Demerol. --Caustic Logic (talk) 03:46, 22 March 2015 (UTC)

spacer: main info here, whoever, whenever, and delete this --Caustic Logic (talk) 03:49, 22 March 2015 (UTC)

One point raised, a crucial one, is the dilated pupils that point away from most opiates (as well as sarin, for example). Just thought I'd check, and it seems mainstream sources don't usually note this difference, but some do. I'm guessing this is a real but little-known fact and most people just swap in general opioid OD symptoms when giving the symptoms for this unusual one. What some reference sites say about pupils in meperidine overdose:
 * rxlist, pinpoint
 * drugs.com, pinpoint
 * drugs.com, different page: dilated
 * drugaddictiontreatment.com, dliated
 * Merck Manuals: miotic (pinpoint)
 * EMS world: "The classic toxidrome associated opioid toxicity is CNS depression, respiratory depression and miosis (constricted pupils)." However, "Mydriasis (dilated pupils) can occur secondary to coingestants or signal cerebral hypoxia secondary to respiratory depression.9 If miosis is absent but other symptoms of the opioid toxidrome are present along with physical evidence on scene, it is safe to treat with opioid overdose as your working diagnosis." (they probably didn't) --Caustic Logic (talk) 03:46, 22 March 2015 (UTC)

Other Chemicals
Focusing on the Mydriasis there are two candidates that may be worth investigating

Insulin

Overdose of Insulin is an established murder method. Mydriasis is a common side-effect.

Adrenaline & Dopamine

A standard last-resort treatment for heart failure including directly into the heart, but via other means before it gets to the desperate stage. Charles Wood


 * This is a useful guide to recognizing an opiate overdose: http://harmreduction.org/issues/overdose-prevention/overview/overdose-basics/recognizing-opioid-overdose/

"The following are symptoms of an overdose: Awake, but unable to talk Body is very limp Face is very pale or clammy Fingernails and lips turn blue or purplish black For lighter skinned people, the skin tone turns bluish purple, for darker skinned people, it turns grayish or ashen. Breathing is very slow and shallow, erratic, or has stopped Pulse (heartbeat) is slow, erratic, or not there at all Choking sounds, or a snore-like gurgling noise (sometimes called the “death rattle”) Vomiting Loss of consciousness Unresponsive to outside stimulus"

This corresponds closely to what we see in the children. I think opiate overdose is the most likely diagnosis because few other drugs cause severe respiratory depression without causing deep coma. Insulin for instance would produce deep coma but not depress respiration. As for the intracardiac injection, maybe they got the idea from the overdose scene in Pulp Fiction. It's obvious that they haven't a clue how to make their act look plausible. The correct use of intracardiac adrenaline is to provoke ventricular fibrillation when a heart monitor shows asystole (flat trace), followed by defibrillation to restore a heart rhythm.

This overdose isn't likely to be accidental. The sources cited by CL emphasize that dilated pupils can occur in an opiate overdose if other drugs have been taken or if (as in child N1) respiration has been depressed enough to cause severe hypoxia. So dilated pupils don't exclude morphine. Meperidine appears to be still widely used in Turkish military hospitals: are meperidine injectors issued to combat medics in the Turkish military (and to JAN?). Pmr9 (talk) 12:12, 23 March 2015 (UTC)

CL, thanks for coming up with the names of the victims. Out of respect, I much prefer to use names instead of ID numbers. My post above can be modified as follows: N1 = Mohammad; N2 = Sara; N3 = Aysha. Mohammad is easy. As for the girls, I believe the child in diapers is the oldest, judging from her size.

I’ve done some pupillary pondering and brushed up a bit on opiates since CL’s query. Until I can flip the pages of my Goodman & Gilman’s Pharmacology to verify what I read online, I’m never totally confident in my conclusions, so I won’t make any. But I don’t see anything here or in online sources I’m relying on that strikes me as being flat wrong, and there are some issues here that could be worth tossing around. The opiate hypothesis is currently the best one going from what I see, and I think it would be very telling for reasons noted below.

As already noted, the vid of Mohammad’s very slight respirations w/ no distress, no struggling, no gasping is consistent with opiate-induced sedation and depression of the CNS respiratory centers. If we had a clear view of his pupils and they were constricted, the diagnosis of opiate poisoning would be very strong. As it is, the kid’s dark, barely open eyes and the dim clinic make it impossible for me to say for sure whether his pupils are constricted or dilated, even with the digital enhancements.

Pmr9 raises the opiate agonist meperidine/pithedine – I’ll go with the trade name “Demerol” as it’s easier to spell. It’s a dirty opiate in that a metabolite of the drug acts on receptor systems other than the opiate system. So the pharmacology is squirrelly. Not only does Demerol not produce miosis like other opiates, but it produces mydriasis. But, like the others, a Demerol o’dose generally shuts down respirations, inhibits coughing, and causes intense constipation. But then again. . . large doses can, in sensitive patients, cause tremors, sweating, diarrhea, and seizures. Dirty drug. Also confounding the pharmacology is the fact that these are all symptoms in adults – kids may be different b/c they metabolize Demerol differently than adults. For instance one source says that kids may be more sensitive to the respiratory depression effect of Demerol.

This means that depressed respiration together with either pinpoint OR dilated pupils would be consistent with opiate overdose.

Would love to get an ER clinician in on this discussion. I think they would agree that opiate poisoning is a pretty good guess. I would be shocked if any clinician could look at these kids and conjecture chlorine poisoning. IOW, chlorine allegations => RED HERRING => false flag => insurgents responsible. Somebody needs to go back to the “Observatory” and check where this allegation came from.

Going with the opiate working hypothesis for the moment, it points to a couple of troubling questions:


 * 1 – How would these kids have been exposed to a fatal dose of Demerol?
 * I mean, this opiate is not going to be “administered” via 155 artillery shells or barrel bombs. It would require some creep holding a kid down and stuffing a handful of pills down her throat or jamming a needle into her butt.  A firm diagnosis of opiate poisoning by itself would virtually demand the conclusion that the insurgents were responsible, just as the diagnosis that CO/cyanide was used in Ghouta virtually demands the same conclusion for that massacre.


 * 2 – Why didn’t the medics reverse the opiate poisoning?
 * The effects of all opiates, including Demerol, are immediately reversed by administration of an opiate antagonist, namely naloxone (Narcan). The opiate depression of CNS respiratory centers is particularly sensitive to naloxone.  Given that the clinic we are seeing seems very well equipped and funded, one might expect that they would be stocked with naloxone and at least Mohammad, who is alive in vid 01, could have been saved.  But then again this is Syria in the middle of a civil war/insurgent attack so who knows what to expect.  Maybe the closest dose of naloxone is in Istanbul.

Pierpont (talk) 17:05, 23 March 2015 (UTC)Pierpont

VDC Records
For what it's worth here, All chemical and toxic gas victims from March 16 = 6, all civilian, and the first poison gas victims listed since some rebel fighters in Harasta in December. As Amnesty noted "The injured included a small number of fighters from the Free Syrian Army armed group, but the vast majority were civilians." And all the dead were civilian. All from the one family from Sarmeen, these records say. Notes for all, unless different: "Six people killed of the same family due to regime`s forces use of chlorine gas via explosive barrel bombs which caused their suffocation and death." Note: as usual, married women are listed with "maiden names."
 * Ayosh Hasan Qaaq AF, 65, one child video of the martyrextra clinic video
 * Waref Mohammad Taleb AM, age 35, Married with 3 Children, other's Name Ayosh Hasan Qaaq. Facebook page individual video - same clinic video
 * Alaa Aljati AF, married with 3 children
 * Sara Waref Mohammad Taleb CF, age 2, Mother's Name Alaa Aljati
 * Aysha Waref Mohammad Taleb CF, 3, Mother's Name Alaa Aljati (no individual video, of course, nor that I noticed shown anywhere)
 * Mohammad Waref Mohammad Taleb CM, 1, Mother's Name Alaa Aljati

They give 5 videos with each entry, 2 extra with Waref (the father) and Ayosh (his mother). Would take a little comparing with Petri's playlist above to see if anything new here. Probably not. --Caustic Logic (talk)
 * 1) Generic Video https://www.youtube.com/watch?v=gPa_6CoYD_o
 * 2) Generic Video https://www.youtube.com/watch?v=J6c6A1Qnbbw
 * 3) Generic Video https://www.youtube.com/watch?v=Vc9cuH1icHo
 * 4) Generic Video https://www.youtube.com/watch?v=JIlBRb2aFzo
 * 5) Generic Video https://www.youtube.com/watch?v=ovPKtOjOx7g


 * One in five was in my YouTube playlist. I added the others. -- Petri Krohn (talk) 22:06, 22 March 2015 (UTC)

March 23 Alleged Attack
Video (all Arabic) claims a second barrel bomb on March 23, hit an orchard-looking area, again with chlorine, but only mild cases this time and no deaths. --Caustic Logic (talk) 09:57, 23 March 2015 (UTC)


 * Another March 23 video (Arabic) has testimony of a woman who lives in the area that was exposed to chlorine gas. I thought it was re: the last attack, but is likely about this one, filmed in an orchard-looking area. --Caustic Logic (talk) 10:05, 23 March 2015 (UTC)