Pictured: Tomohisa Shoko, the corresponding author.
On 11 March 2011, at 2:46 pm Japan time, a massive 9.0-magnitude earthquake struck off the Pacific coast of Japan’s Tohoku (northeastern) region. The maximum seismic intensity, level seven (on the Japan Meteorological Agency’s scale), was recorded in Kurihara City, northwestern Miyagi Prefecture. About 25 minutes after the quake, enormous tsunami waves began pounding the Pacific coastline of the Tohoku region, causing massive damage to several coastal towns. This was the first mega-disaster in which modern cities were struck by a massive tsunami. As of 6 April, the National Police Agency reported the total number of fatalities attributed to this disaster nationwide at 12,431, with 15,153 people missing and 2869 people injured. The damage was the worst in Miyagi Prefecture, with 7571 dead, 6312 missing, and 1122 injured. By comparison, the Great Hanshin-Awaji earthquake of 1995 left 6308 dead, 3 missing, and 43,117 injured. The morbidity/mortality ratio was 0.10 in the recent great eastern Japan earthquake and 6.84 in the great Hanshin-Awaji earthquake. The extremely small number of injuries – compared with the number of people dead and missing – is the hallmark of a tsunami disaster.
Four hours after the earthquake, four doctors, one nurse, and two administrative workers with Japan Disaster Medical Assistance Team (DMAT) certification were sent from Tokyo Medical and Dental University (TMDU) to Miyagi Prefecture. We reached Sendai City at 4:00 am on 12 March and provided hospital support at Sendai Medical Center, the prefecture’s largest disaster-base hospital. At that time, 25 DMATs (about 130 people) had assembled at that hospital. Of those teams, 18 provided support in six-hour rotating shifts in the hospital’s emergency department, five worked on-site at a rescue command post in the tsunami-stricken region along the coast, and two worked at the staging care unit set up at the Self-Defense Force’s Kasuminome base. By the night of 13 March, another 52 DMATs had assembled at Sendai Medical Center (for a total of 77 teams and about 390 personnel).
The emergency department support teams were divided up to serve at a triage post at the hospital entrance, in a red area (pictured) established for treating critically ill patients, a yellow area for treating moderately ill patients, or a green area of treating those with minor injuries. Another team cared for those being prepared for transport to remote locations outside the disaster area. Our TMDU team served as the lead team of the red area on 12 and 13 March. Sendai Medical Center sustained only minor structural damage due to the earthquake, but had to rely on its own power generator for electricity due to widespread power outages throughout Sendai. Computed tomography scanners could not be used, and only some of the medical equipment, such as basic X-ray machines and emergency blood testing equipment, could be operated. Some of the operating rooms were still functional, but only minor surgery could be performed. Most of the hospital staff assembled at the hospital and worked without sleep from the time the disaster struck.
The table shows the number of patients that came to the hospital for emergency care. The period from the initial disaster until 12 March saw the peak arrival of critically injured patients. However, patients transported from isolated coastal communities located far from Sendai began coming in on 14 and 15 March, creating a bimodal distribution of patients. Patients with injuries directly caused by the earthquake and tsunami, such as fractures of the pelvis, spinal cord injuries, and lower leg compartment syndrome, arrived at the hospital within 24 hours after the initial disaster; most of them were also affected by hypothermia as a result of having been exposed to the elements while waiting for rescue. After the first 24 hours, most of the patients suffered from diseases incurred after evacuation.
The Japan DMATs, which were developed after the great Hanshin-Awaji earthquake, have been designed to provide life-saving medical treatment (such as medical stabilization of severe patients in the most affected areas and medical evacuation outside of the devastated area) for crush syndrome and severe injuries commonly seen after earthquakes. In this disaster, DMATs led by emergency care physicians and trauma surgeons were able to get into the disaster area during the ultra-acute phase and many were able to swiftly mobilize and swing into action. However, in this tsunami disaster, there were not as many critically injured patients requiring life-saving treatment as had been envisioned, such that the activities of the DMATs were limited. On the other hand, more than 300,000 victims who lost their homes and all their possessions in the tsunami were forced to live in poor conditions at evacuation shelters.
A great need exists to provide medical care to these evacuees, and that need will be a long-term one. Systems must be established for providing medical care in the aftermath of a tsunami disaster that strikes a modern city, and these systems need to be different from those established for managing conventional earthquake disasters.
Tomohisa Shoko (pictured) is a Japanese trauma surgeon and is a assistant professor at the Shock, Trauma, and Emergency Medical Center, Tokyo Medical and Dental University Hospital of Medicine (Japan).
Yasuhiro Otomo is professor and chairman of the Department of Acute Critical Care and Disaster Medicine, Tokyo Medical and Dental University Graduate School of Medicine and is the director, Shock Trauma and Emergency medical center,Tokyo Medical and Dental University Hospital of Medicine.
Atsushi Shiraishi is an emergency physician and assistant professor at the Shock, Trauma, and Emergency Medical Center, Tokyo Medical and Dental University Hospital of Medicine.