Tokyo Subway Sarin Attack by Aum Shinrikyo

Tokyo Subway Sarin Attack
by Aum Shinrikyo
Lessons Learned
from medical perspective
Mitsuyoshi Urashima MD, PhD, MPH
Jikei University School of Medicine
• The use of chemical, biological and radiological weapons
by terrorist group remains a potent risk to the world.
• At March 20th, 1995 in Japan, Aum Shinrikyo (Japanese
apocalyptic cult), dispersed sarin, a chemical weapon, in
the 4 Tokyo subway system, where 13 stations locating
in the central government, were affected simultaneously,
killing 13 people and prompting 6,000 others to seek
hospital treatment.
• In this presentation, I will describe about the importance
of information sharing among medical, public health and
law enforcement in early phase of crisis, which we failed
to do, from medical perspective.
• 7:00-8:10, On Monday March 20, in 1995
• At the peak of the morning rush hour
• The chemical agent used by Aum Shinrikyo (Japanese
apocalyptic cult), liquid sarin (35%: relatively lower
conc.) contained in plastic bags (900mL) which each
team then wrapped in newspaper.
• Carrying their packets of sarin and umbrellas with
sharpened tips, the perpetrators boarded their appointed
• By leaving the punctured packets on the floor, the sarin
was allowed to leak out into the train car and stations.
• This sarin affected passengers, subway workers, and
those who came into contact with them.
As the train approached ShinOchanomizu Station, he punctured
one of his two bags of sarin, leaving
the other untouched and exited the
train at Shin-Ochanomizu.
Center of Tokyo
Governmental function
The train proceeded down the line
with the punctured bag of sarin
leaking until 4 stops later at
Kasumigaseki Station.
There, the bags were removed and eventually disposed of by station attendants,
of whom two died.
1st bag was
2nd bag was
2 bags of sarin
release here
Hibiya line 1
Sarin release
• At the day, first patient was transferred by an ambulance
into our hospital around 8:30 that is just rash hour time in
Japan. The patient has been complaining “Dyspnea” and
“Visually darkness”. Soon after that, number of patients
visiting our hospital increased.
• Almost clinical departments are busy for meetings or preparedness of
operations. Doctors on night duty usually transfer patients’ information
Ordinal outpatient clinics start from 9:00AM. That’s why; it was very
hard for nurses in emergency room to catch clinical doctors to see the
patient at emergency room. At the time, we had not “Department of
Emergency Medicine” yet at the time. One surgeon and one physician
on duty at the day coped with these increasing patients. During initial
phase, patients who complained narrow vision were referred to
ophthalmology and patients who complained dyspnea were treated
with oxygen inhalation and drip infusion on beds at ER.
• In a short time, number of patients at ER overflowed and further
patients were laid down on the waiting sheets at other outpatient
clinics and open beds at clinical wards. At this time, many doctors
came to treat these patients on their own judgment.
• The surgeon who was on duty and saw first patient became the
leader and tried to uniform treatment strategy. As contracted pupil
was the common sign among the patients, “atropine” was
considered as first choice of therapy. However, before decision
making, he asked opinions of Professors in department of forensic
medicine and public health. It was around 9:30 AM: One hour after
accepting the first patient.
Causative agent could be
PAM would be
the first choice
Professor Takatsu
Forensic Medicine
• Two professors concluded that causative agent could be
organophosphate and PAM would be the first choice. The doctor
asked hospital pharmacy to find that there were only two ampoules
of PAM in the hospital. Immediately, the surgeon asked chief
pharmacist to collect ampoules of PAM as many as possible around
greater Tokyo area. Two ampoules of PAM were used for one with
unconsciousness and another with hypotension. Soon, enough
amount of PAM had arrived and protocol was written in a paper of
A4 and copied to handout to places where the patients were laid.
9:10AM Metropolitan Fire Department
informed hospitals that “Acetonitrile
(methyl cyanide)” without any proof.
10:15, Prof. Yanagisawa in Shinshyu
university hospital and chief of
neurology, who experienced Matsumoto
Sarin Attack a half year before sent the
FAX to the hospitals in Tokyo including
ours informing suspicion of Sarin.
• The number of patients inflamed. The president of hospital next took
over the leader for this chaos and some doctors were dispatched for
triage: patients with contracted pupil alone were got together into an
• At 10:15, doctors in Shinshyu university hospital who experienced
Matsumoto Sarin Attack a half year before sent the FAX to the
hospitals in Tokyo including ours informing suspicion of Sarin.
After 11AM, “Sarin” as a causative agent
was informed by law investigators.
• After 11AM, “Sarin” as a causative agent was informed by law
• Responding to this information, clothes of these patients were taken
off for decontamination. Patients in Pediatric and Obstetrics were
transferred to other wards.
• Other hospitals having patients exposed to Sarin tried to gather PAM
after getting the information released around 11AM. However, as we
had collected PAM around greater Tokyo area as many as possible,
they needed to transport distant area in Japan. Thus, they could use
PAM for the first patient as early as 2PM.
• We shutout media reporters to protect patients’ privacy. Thus, our
activity during Tokyo Sarin Attack was not well known to Japanese
public. However, we saw more than 2,000 patients for three days
without any death.
Hibiya line 2
One passenger kicked the sarin
packets out of the train and onto
Kodenmachō Station's subway
platform. Four people in the station
died as a result.
Passengers stumbled out and
collapsed on the station's
platform and the train was
taken out of service.
• Video
Tokyo Metro
10:15 FAX from
8:10 A conductor informed “Explosion”
Sent emergent cars to the scene
8:35 Stopped Hibiya Line
9:27 All metro stopped
Total 13 stations
Dispatch doctors to the scene
9:10 Acetonitrile
Not shared
Metropolitan Fire Department
Control center
Could not dispatch
Many causalities
other patients
Coordinated rescue
riot police
West side of Japan
Inspection of the attacked subway cars
By Shinkan-sen
by Air
National Research Institute of Police Science
11:00 Press conference
Self defense forces
Causative agent is sarin!
Public Health
We, medical facilities, should
have connections with raw
enforcement from ordinal time,
through drill or table top