Cloudy Judgment

Vladmir Putin's decision to storm and gas a theater in Moscow -- where Chechen terrorists had taken about 700 hostages -- was an obvious call; circumstances had left him with little choice. But if the decision to storm the theater was fundamentally just, the execution of the operation by security personnel raises a number of troubling questions. And most disturbing is the question of whether more than 100 lives were sacrificed carelessly because of a lack of adherence to basic principles of emergency medicine and rescue.

It is difficult to control the concentration of a gas pumped into a building the size of the theater. In a hospital operating room, doctors use precise instrumentation to keep the concentration of anesthetic gases somewhere between a therapeutic and a toxic range. In the Moscow theater, no such regulation was possible, and there must have been pockets of greater concentration of the gas where anyone present was immediately overcome. These poor conditions were compounded by the debilitated state of many of the hostages, and the possibility that some had pre-existing illnesses.

Reports from Moscow indicate that adequate emergency personnel were not available on the scene. This omission was inexcusable. Rescue operatives should have been equipped with oxygen, intravenous lines and an opiate antagonist known as nalaxone or narcan. Since the gas used was an opiate derivative -- as has now been confirmed by Russia's health minister Yuri Shevchenko -- it could have been immediately reversed by narcan. And because the effects of the opiate in question (fentanyl) may last for two to three days, intravenous drips of narcan could have been used on each patient in the hospital to easily reverse the effects of the opiate until it had completely worn off.

Instead, doctors at the hospitals receiving these patients were -- by their own admission -- not told which gas had been used. They didn't know to use narcan at first, and were instead forced to battle the overwhelming effects on breathing and blood pressure of the unopposed opiate gas. Unfortunately, opiate derivatives may cause patients to stop breathing or their hearts to stop beating, causing permanent brain damage or death. Significant numbers of the hostages were probably affected in this manner.

Medical students in Russia are routinely trained in the properties of such military gases, ostensibly so they are prepared in case Russia is attacked by an enemy wielding chemical weapons. Yet the Russian military was too secretive in the hostage rescue to inform its own doctors which type of gas was being used free the hostages. This omission undoubtedly cost lives.

Yes, this military action was put together in a hurry, with little time to organize a cohesive medical rescue force. But there was plenty of time for oxygen, for informed calls ahead to the hospital -- and plenty of time for narcan.

Yes, the omissions were the result of oversight rather than calculated malice. But a needless risk was added on top of an already perilous situation by subjecting hostages to potentially toxic gas without ready relief.

Now that this powerful gas has made an appearance, some have wondered if we might someday see it used on civilian populations here in the United States by terrorists. Our response to this possibility must, of necessity, be one of preparation, control of unnecessary fear and the knowledge that narcan -- the opiate antidote -- is available on every emergency cart in every hospital in this country.

In Russia, there are surely no lack of available emergency medical teams either inside or outside the military. But the key in this situation would have been to deploy them in a timely and effective manner. And this clearly wasn't done. Communication and full disclosure are essential to lifesaving medical practice. Secrecy is destructive in the face of a mystery ailment. Diagnosis and intervention need to be based on the fullest medical history possible and the most decisive medical action. Knowing that this gas was going to be used -- even at the last minute -- why did the government not include military physicians in the planning and assault?

Back here in the United States, we have already experienced a fumbling defense when it came to the anthrax letters of a year ago. Our agencies -- specifically the Army, FBI and the Centers for Disease Control -- failed to cooperate and readily exchange information at a crucial juncture of the anthrax investigation. Some lives were lost as a result of secrecy. If our law enforcement agencies found themselves in a similar crisis to the one that just unfolded in Moscow, would they make the same mistakes? Surely the CDC and the biowarfare division of the army are prepared for such horrid scenarios -- but in action against any threat they must also keep in mind the basic human rights of any civilians at risk. In my culture as a physician, most fundamental among these rights is the principle of equal access to life-saving treatments when life is put in jeopardy.

This principle is no different for a doctor trained in Moscow. Luda Bronfin, a U.S. neurologist who attended medical school in Moscow and was born less than two miles from the assailed theater, told me that "secrecy and paranoia are part of the culture left over from the Soviets. It interferes with cooperation and planning. The Russian army wasn't preparing to use this gas; they were training with it in case it was ever used on them."

We must learn a lesson here in America from what took place in Russia this past weekend. Our law enforcement officers must trust our doctors and health care workers to protect us against the ill-conceived use of medical technology. That way, even in the worst case, we can reach for an answer rather than a gas mask.

Marc Siegel is an assistant professor of medicine at New York University's medical school. He is also a practicing internist.

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