I would like to introduce Dr. Konichi Ogura. he is from Kanazawa, Japan, he works at the Center for Emergency Medicine at Kanazawa's Medical University Hospital. He is a board certified physician in Japan, in acute medicine and neurosurgery. He has experienced four earthquakes in Japan as a physician. And today he is going to talk about those experiences and the structure of Japan's response to a disaster. [INAUDIBLE] >> [FOREIGN] >> Hello, my name is Konichi Agura, and I work for the Kanazowa Medical University Hospital. Today I would like to talk about the great east Japan earthquake that occured about two years ago. And the Japanese system for disaster medical care. In Japan I work as an emergency physician. Though I work at the for emergency medicine at Kanazowa Medical University. When a disaster occurs in Japan emergency physicians like me get involved in helping with the disaster. Actually I participated in the medical care for the Great East Japan Earthquake as a member of the Japanese DMAT, Disaster Management Assistance Team which is quite different from the American DMAT. As a physician and as a member of a medical team, I've participated in the medical care for four major disasters in Japan over 20 years. Two earthquakes among those disasters are known world wide. One is the Great Hanshin earthquake, and another is the great East Japan earthquake. Allow me to introduce myself before I talk more about the Great Earthquake. As I mentioned earlier, I live in Kanazawa City in Ishikawa Prefecture in Japan. Although Japan is a very small island, Kanazawa is located facing the sea of Japan, which borders with China, Russia, and South Korea. Here you can the location of Tokyo and Kyoto. Kanazawa once flourished as a castle town. About 500 years ago, Samurai controlled this area. There was an era called EDO during which the Samurai were in control. The greatest feudal lord was Tokugowa who lived in Tokyo. The second greatest feudal lord was Maeda who controlled the town of Kanazawa. Kanazawa is very rich in history. Another famous person who was from Kanazawa was Jokichi Takamine. He was actively engaged in the development of adrenaline, something that would be well-known by many in the health care profession. About 1090 years ago, in 1912 Takamine sent 100 cherry blossom trees to Washington, D.C. With a governor of Tokyo at that time. I recently visited Washington and enjoyed the experience of seeing the beautiful cherry blossoms in the nation's capital. Let me go back to talk about the disaster. The Great East Japan Earthquake occurred on March 11th about two years ago. It occurred mainly in the northeast coastal area of Japan, at 2:46 p.m. On that day, I'd just finished my university work before noon, and went back home. Since I was planning to go to Tokyo for my business trip, I was preparing to leave. My TV was on daily programming, but then all news coverage showed that a tsunami was surging to the coast. And cars in the market areas were caught in the water like miniature toys. What struck me at the time were the events of September 11th in America. At that time, I was watching TV without paying much attention. And the newscaster said it was an accident when the first airplane crashed into the building. I kept watching the footage of the situation as the second airplane crashed. While its live coverage was distributed to Japan at the same time. I was wondering what happened in my mind. Then they started speculating if it was terrorism, and that made me realize that it could be terrorism. When the first airplane crashed, no one would of thought it would become such a big incident. In any disaster when it strikes, it is hard to understand what happened and if it will prove to be a big disaster later on. When a calamity strikes we can't delay decisions by waiting to see how far the influence spreads. Therefore we try to recognize the disasters in the making by using three key words. The three key words are same place, same time, and number of injured people. When we get these keywords, we assume a disaster is evolving and we take action. In the recent explosion incident in Boston. I heard that health care professionals made very quick actions. In this instance I felt the system in the United States is much more developed. I heard some hospitals recognize this was a disaster. And started their preparations just a few minutes after the explosion. >> [FOREIGN] >> To get back to the great East Japan earthquake, it measured 9.0 on the Richter scale and post quake features included a tsunami surging to the coast of East Japan. We had never experienced such a big disaster in the last 20 years. Speaking about medical care as I showed in the first slide, at the time of the great Hanshin earthquake, the biggest problem was severe trauma and an acute period. However, in the Great East Japan earthquake due to the disastrous effects of the tsunami There was a dichotomy or mild case trauma. Or critical case trauma, which we almost couldn't help. The purpose of D-MAT is to figure out how to save severe trauma patients, in an acute period, when a disaster occurs. However, since there was such a dichotomy between case types. We could say that we as DMAT didn't have much opportunity to play our active role in this disaster. We as DMAT members received a text message to our individual cell phones from the Government Health, Labor and Welfare Ministry. That we should prepare and be ready to go to the disaster sites. When I was watching the scenes of the disaster on television that day, I received such a message to my cell phone. As a matter of course, I cancelled my business trip to Tokyo. Then went back to the school to prepare for my departure. I would like to show you some clips of the scene when the Tsunami was surging to the coast of the Tohoku area of East Japan. Next, I would like to talk about the overview of Japanese DMAT. As I mentioned earlier, Japanese DMAT is quite different from American DMAT. A team consists of five members. For your information, about 380 teams without about 1,800 people were engaged in this disaster of East Japan. Since each team consists of a small number of people, it is different from American DMAT, in which a small scale hospital goes to the disaster site. Each team includes physicians, nurses, pharmacists, and administrative staff for logistics. The purpose of Japanese DMAT which consists of five members is to provide medical care for the period of 48 to 72 hours, about three to four days after a disaster occurs. The Japanese DMAT was established after the Great Hanshin earthquake in 1995. Under the regrettable idea that we could have saved more people during the acute period, which is 48 to 72 hours. We assessed that we suffered about 500 preventable trauma deaths in the great Honshin earthquake. Therefore, DMAT was established for the purpose of saving trauma patients, which become problems in the acute period. There are two purposes in the Japanese DMAT. One is to move the patients from the disaster area to outside. Since the medical resources are limited in the disaster area, it is difficult to provide the medical care for a lot of patients. Therefore, we try to move the patients to the outside of the disaster area as quickly as possible to save more patients. SDF, Self-Defense Force of Japan, is engaged in this logistical transportation. Another purpose is to provide the medical care inside of the disaster area if there is not a hospital which can still function as a medical facility. Let's go back to the story of the great East Japan earthquake. We departed Kanazawa at 6 pm in conditions of heavy snow. In Japan, DMAD is in charge of acute care at the time of a disaster. We are called out by the government, health, labor and welfare administrator, but we belong to each prefectoral and city governments. Moreover, we act as a unit of each prefactoral and city governments. After we depart, we correspond with people in each prefectural and city governments who control the D mat. And it is decided where to go. The prefectures, which were affected majorly, where Fukishima prefecture, Miagi prefecture and Ewati prefecture. For example, if this is Myagi, its prefectorial government basically handles the whole disaster, and the demat is handled in their controlling teams. Also, medical emergency centers and hub hospitals in the disaster area are designed in each prefecture to support the controlling teams. Such relatively large hospitals control DMATs, although the prefectural government is the top organization which orders commands. Anyway, we departed for Fukushima prefecture after we left Kamazawa. On the way to Fukushima, we didn't know about the nuclear problem through the media yet. It took three days after the earthquake for us to know about this nuclear incident. We were supposed to go to Fukushima first, but in the communication with each DMAT and the prefictorial governments and hub hospitals in Fuuishima and Miyagi, we found out there were enough d mats in Fukushima already, therefore we changed our destination to Sendai City. In Miyagi. To tell the truth, we knew for the first time the scale of this disaster through the television news in the car on the way to Miyagi. As a means of gathering information while traveling, we've exchanged information by transceivers between cars heading for the same destination. This is because we couldn't use the regular cell phones from certain areas. Moreover we used satellite telephones between DMATs in each prefectoral government such as Miyagi and Fukushima and us. Also, we got traffic information from police organizations, fire organizations and other DMAT teams. In Japan, our communication was pretty smooth between the same organizations. But it didn't flow well between different organizations, such as police, fire, emergency medical teams, and so on. However, as we have done relatively big disaster training recently after the great Hanshin earthquake, it has become easier to gather information. On the way to the disaster site this time, we got information more easily from other organizations because we have known each other through the training. For your information, there are 47 prefectural governments in Japan. This disaster occurred in the area of the Northeast side of Japan, which is the Northern part of Tokyo. In particular, the east coast was the main affected area. It may be a bit difficult for you imagine how small Japan is compared with the US. It would be easier for you to think of the Tohoku area as one of the states in the US. Then you can think of Iwate Prefecture, Miyagi Prefecture, and Fukushima Prefecture as a collection of several counties within an american state. Anyway, in Japan, in a disaster, we act as units of each prefectural and city governments. Actually in Japan, when a disaster occurs, like the great East Japan earthquake. The prefectural government plays a central role as an organization. On the medical side, a large hospital acts as a secondary hub. We gathered at Sendai Medical Center as a secondary hub. And performed our roles by receiving the directions. Most of the directions are made by the prefectural government. However, working D-Mat groups came from all over Japan to provide medical care. The organizaions which were involved can be seen here. During the acute period, prefectural organizations, especially disaster medical care coordinators in each area. Play central rules in addition to the DMAT. Relatively large hospitals fulfill the rule of disaster medical care by working as hub hospitals and the Health, Labor and Welfare Ministry supports the whole. Functioning as working groups, DMAT works for the first three to four days after disaster occurs. In Japan, firefighters and emergency rescue teams belong to five organization. These organizations handle medical transportation in disaster areas where they support our DMAT. Also transporting patients for long distances such as from disaster areas to perimeter areas is done by the SDF, Self Defense Force. This is schematized for clear understanding. The prefectural government is in the center, but the DMATs play a major rule during the acute period. And the health, labor, and welfare ministries support that. The SDF and fire organizations are in charge of transportation. It wasn't until 3:00 or 4:00 am the next day that we arrived at Sendai Medical Center which was serving as a hub hospital. We began with triage There was an SDF station near Sendai Medical Center with an airport at which impromptu flights could take off and land. Therefore we used the facility to gather all the people who had evacuated from all over Miyagi, so that we could group them into mild, moderate, and severe levels. If the patients were in moderate or severe conditions, we could transfer them to Syndai Medical Center. For mild condition patients, they could go to community centers or to other facilities which were being used as evacuation centers. At first we planned to do triage for more than 1000 patients. However, due to poor ocmmunication under the disaster, the number of patients were in the dozens. As for triage, I believe it is run the same way in the states. I heard the appropriate triage was run following the recent Boston Marathon explosion. As you see here, the patients in red are the ones whose vitals are in changing and are in extreme need of urgent care. The ones in yellow mean that they need some treatment but can wait a little longer. The ones in green are in relatively mild condition, and are able to walk. The black ones are the ones that have no other chance of survival. Depending on the disaster situation and the number of injured patients, disaster medicine is different from regular medicine. And we need to save as many as possible, therefore we wouldn't provide active care to all patients, after the triage we went to the Hub Hospital to help support those inside. As I mentioned earlier, since there was a dicotimus concentration of mild injury patients and patients who couldn't be saved, those who were engulfed by the Tsunami. I didn't have many chances to see relatively severe patients. In this picture, the patient who I was treating had bumped and cut their head while cleaning room after the earthquake. I was suturing the wound. In addition to this kind of patient, I treated mild trauma patients as well as those who were in need of daily medicine. We were concerned that the original staff who worked in this hospital, not the dmat team members, would be getting very tired. However, we found that they were worrying about us getting tired. In fact, there were hospital staff members whose families were victims of the disaster, and in some cases, there were staff who lost their families. Despite such a situation, they kept working matter-of-factly. I wondered how they were able to work so calmly. But actually people in Tohoku are very patient because of the severe snowy climate. When I asked how they managed to handle the situation, they said they had just had disaster training which simulated exactly this type of earthquake a few days earlier. They said they were doing the same thing as if they were in training they were dealing with this disaster with the same feelings as during the training exercises therefore I have no doubt about their ability to work so calmly. Speaking about disaster training, the best way is to simulate actual patients and disaster sites in realistic time frames. However, in this kind of training there is a need for people and money. Therefore, we introduce different solutions aside from more actual training. I will talk about it later. As I repeated several times, in the great East Japan earthquake, for the acute period, there were mild patients and very severe patients who couldn't be saved because of the tsunami which had such a large influence. Honestly speaking, we as DMAT didn't have many chances to perform our roles. Then after three to four days, we presume the chronic diseases or infections diseases would become more of a problem. However, since the damage was very huge, we decided to gather more information about the medical care situation in Miyagi Prefecture as a whole. In a disaster, there are times that we cannot use the regular communication tools such as cell phones. Like when we were traveling from Kenazawa. Since at that time, we couldn't use such tools. We decided to go to the actual sites. We went not only to hub hospitals, but also other hospitals or evactation facilties and gathered information directly. In this slide, I was talking to a top official of a hospital where I went to gather information. He told me that some of their problems were lack of oxygen for the patients who get oxygen therapy at home, and dialysis solution for the patients who have dialysis. When this disaster occurred, at first we didn't go to the coastal areas because we wouldn't have been able to save the people who were engulfed by the tsunami. But after three to four days, since we had more DMAT teams, we went to see the coastal areas where more than 16,000 people passed away. On the fifth day, we prepared everything by ourselves, such as food, and even medical supplies, in self-contained fashion, and went to the site. Generally medical supplies and food run out after about three to four days. So we went back home to Kanazawa, on the fifth day. [FOREIGN] On the way back to Kanazawa, we saw a lot of passing cars which were going toward the disaster area. Was it okay for us to go home now? After witnessing the overwhelming scene of the coast, we were wondering if there were other such places in Japan. In spite of the situation we had seen, we were being sent home. But was it alright for us to return. With the feeling that we had unfinished work, but a great shortage of medical supplies we went home with strong reluctance. I have been talking about acute care so far. From now on, I will talk about how medical care is expanding beyond acute care. Basically, although this kind of disaster medicine is provided at the prefecture level, the local government and national government also provide their support. However, in the chronic phase, different organizations, such as some private organizations, Japan Red Cross, Japan Medical Association, Japan Dental Association, Japan Nursing Association, are more involved. Instead of DMAT, these medical teams were given more support. Also, each prefecture provides medical support by dispatching medical staff. As you see in the chart, so many organizations are involved during this period. Again, disaster medicine, especially for the acute phase of disasters, honestly did not start in Japan until after the Great Hanshin earthquake in 1995. What is disaster medicine? As you know, regular medical care is doing our best for each individual patient. However in disaster medicine, you have to save as many patients and injured people as possible, with very limited medical supplies. As I explained in my talk about triage, what we are aiming for is that we focus on saving as many patients as possible, which means disaster medicine is vastly different from regular care. It is very unusual for medical staff to have training for mass casualties, which is extremely different from regular medical care. However, the necessity of disaster training is emerging. And as I mentioned earlier, in the hub hospitals and Sendai Medical Center that I described, they had had such training just a few days before this great earthquake. However, since this kind of training requires people, time and money. It is difficult to offer it regularly. Another solution involves theoretical training with some simulation. We have disaster training with Emargo training system. Using a manequin sim patient, which was developed in Sweden. It's also important to learn some personal skills as written here as healthcare professional. This Emergo Training System is developed in Sweden. We use this as a syn patient using actual time. Along with the syn patient, we do this training using a whiteboard, as you see on the table. In this training with the whiteboard, we set up disaster sites, emergency aid stations, and several departments in a hospital. Then we moved the sim patient from the disaster site to hospital. For this type of disaster training, the main points are the three T's, which are triage, treatment and transport. What we do, is attempt to save patients from the disaster site and provide triage to divide them into groups by degree of severity. For severe patients, we provide some treatment to them, so they can endure transport. Then we transport them to appropriate hospitals. In this way, regardless of whether disaster is big or small, during triage is the main task. Upon doing the three Ts, triage, treatment, and transport, the important thing is to remember CSCA as a concept. C means to make sure you have a chain of command. S is safety. Of course this includes our safety while saving patients, safety of sites, and safety of patients. Another C stands for communication. It is very important how we communicate our chain of command and information. Finally, A stands for assessment at sites. In Japan, our chain of command within similar organizations usually went well in the past. However, cross organization relationships were not very good. But now we realize, if we don't do well in the chain of command, we cannot support disaster medicine well. Recently, especially after the great Henshin earthquake. At a large scale and at a national level, we have disaster training, and that has improved across organization relationships. We've been developing better relationships now that we know each others' faces. Cross-organization relationships continue to get better. When we convey information of the disaster site, we remember the initials M E T H A N E. Major incident, exact location, type of incident. Hazard, access, number of casualties, emergency services. We organize the information using METHANE. This is very useful to convey information regarding what kind of disaster occurred at a site. Another purpose of disaster training is to help improve this type of manual. It is very important to continue to improve the disaster manual, through disaster training, with a PDCA cycle. That is plan, do, check, act. As I mentioned earlier, in addition to all this, it is very important to develop a good human relationship through disaster training, in case a disaster occurs. When I was on the way to the site at the time of the Great East Japan Earthquake, it was very easy for me to get information because I had personally known people in the police and fire departments. Also when I was working at the disaster site. It was more comfortable and easy for me to accomplish our work, because I had met many other DMAT team members at various locations in the past. Through disaster training, I realized that the development of the human relationship is extremely valuable and very important. From now on through a stronger globalization of the world. When a big disaster occurs, such as the Great East Japan Earthquake, it has a far reaching effect. All around the world, including the United States of America. And often, an economical aspect. Through such preparation, by developing good relationships between people all over the world I believe our ability to respond to disasters will continue to improve and will run more smoothly. Thank you very much. [BLANK_AUDIO]
