Abstract
On March 11, 2011, at 2:46 PM Japanese Standard Time, an earthquake registering 9.0 on the Richter scale occurred with an epicenter located approximately 43 miles east of the Tohoku region along the eastern coast of Japan. The effects of the earthquake were largely felt on the island of Honshu (Figure 21.1), Japan’s largest island. From its epicenter, the earthquake generated a reported 124–133 ft tsunami wave which inflicted devastating damage, striking Miyagi, Iwate, Fukushima, and Ibaraki Prefectures (Figure 21.2). Final tallies report at least 15 000 fatalities (with ranges from 15 188 to 20 000+), 8742 missing persons, 5314 injuries, and 130 927 displaced persons.
Introduction
On March 11, 2011, at 2:46 PM Japanese Standard Time, an earthquake registering 9.0 on the Richter scale occurred with an epicenter located approximately 43 miles east of the Tohoku region along the eastern coast of Japan. The effects of the earthquake were largely felt on the island of Honshu (Figure 21.1), Japan’s largest island. From its epicenter, the earthquake generated a reported 124–133 ft tsunami wave which inflicted devastating damage, striking Miyagi, Iwate, Fukushima, and Ibaraki Prefectures (Figure 21.2).1 Final tallies report at least 15 000 fatalities (with ranges from 15 188 to 20 000+), 8742 missing persons, 5314 injuries, and 130 927 displaced persons. 2,3,4
In addition, the Congressional Research Service reported the destruction of 432 047 homes, 3700 roads, and 27 019 additional buildings.2 The majority of casualties and damage were likely secondary to the tsunami and not the result of the earthquake itself. The United States Geologic Survey reported a total economic loss in Japan estimated at $309 billion with disruption of electricity, gas, water, telecommunications, and railway service. A devastating consequence of the tsunami was a loss of electricity at the Fukushima Daiichi Nuclear Power Plant in the Fukushima Prefecture, which led to a loss of cooling capacity, resulting in a nuclear accident. This nuclear event was declared at the highest level on the International Nuclear Event Scale and contributed to the suffering of the Japanese people as a result of a “triple disaster” (i.e. the combination of earthquake, tsunami, and nuclear disaster).5, 6
Figure 21.1 The island of Honshu.
Figure 21.2 USG humanitarian assistance to Japan for the earthquake and tsunami.
A comprehensive understanding of this post-triple-disaster environment will establish a foundation of knowledge that will assist anesthesia providers in synchronizing health care delivery with aspects of disaster response in the future. This introduction to the Great East Japan Earthquake and Fukushima Daiichi Nuclear Disaster sets the stage upon which an understanding of the response may be appreciated. The aspects of the Japanese response to this triple disaster include: (1) The initial response during the immediate aftermath of the event, (2) the available methods of communication, (3) the magnitude and anticipated casualty load, (both acutely and chronically in the setting of ongoing inpatient care delivery), (4) the available medical resources, (5) the available facility resources, (6) facility activity/limitations (patients, water, electricity, personnel, logistics, etc.), and (7) the ability to transport patients, establish hardened supply lines, and record actions for process improvements in the future.
Immediate Aftermath:Initial Response with Focus on Force Protection and Threat Neutralization
In the aftermath of the earthquake and tsunami, Prime Minister Kan established an Emergency Response headquarters in the Ministry of Defense. A state of emergency was not declared since the National Diet of Japan was in session and was capable of coordinating legal action with the Cabinet in response to the disaster. Japanese Disaster Response Basic Law was enacted dictating the delivery of care coordinated through prefectural and municipal governments.7 Foreign Minister Matsumoto formally requested the assistance of United States Forces Japan via the United States Ambassador to Japan (John V. Roos) on the evening of 11 March 2011. As the evening progressed, Prime Minister Kan subsequently declared a nuclear state of emergency and directed the evacuation of residents within 3 km of the nuclear power plant. Within 24 hours, residents within 20 km were ordered to evacuate. By March 15, residents living within 20–30 km were ordered to remain indoors (Figure 21.3).8 By March 17, the United States Department of State had authorized the voluntary evacuation of between 9000 and 10 000 family members and dependents. This scale of personnel evacuation/sequestration must be considered with regard to force protection, and employee assignment in the aftermath of such a disaster.2
Figure 21.3 US Military stations on Okinawa.
Establish Communication
As response forces activated, it became imperative to establish and maintain communication and logistical support. The Japanese Emergency Disaster Response Headquarters coordinated with the Ministry of Defense in the dispatch of Self-Defense Forces, police emergency units, firefighters, and emergency medical teams. With the deployment of up to 107 000 personnel, this was the largest operation since the establishment of the Japanese Self-Defense Forces.9 Logistical coordination occurred via a relief hub at Sendai airport.2 The United States Air Force Base, Misawa, located in the Aomori Prefecture, escaped the disaster with minimal damage and was identified as a forward operating base for United States Forces and Japanese Self-Defense Forces.2 Furthermore, the Yamagata airport was identified as the base for a Marine Expeditionary Force (MEF) command and control (C2) headquarters/forward refueling point.2 The 31st Marine Expeditionary Unit (MEU), consisting of ground, aviation, control, and logistics personnel, established a headquarters in Matsushiman after disembarking from the USS Essex.2 The United States, through the State Department’s Agency for International Development (USAID), also dispatched a Disaster Assistance Response Team (DART), which included urban search and rescue (USAR) capabilities. Author H. Fukunaga reported the establishment of communication with the Prefectural Health Division Representative, thereby enabling coordination with surrounding hospitals, pharmacies, and medical associations. With the closure of private medical practices in the aftermath of the earthquake, H. Fukunaga also describes the establishment of communication and collaboration of government and military physicians with private practice physicians at evacuation shelters to assist with delivery of patient care.10
Nakagawa describes the challenges of in-hospital communication, given the loss of power in the immediate aftermath of the disaster.11 Regardless of the role that a provider may have in normal day-to-day hospital activities, it is easy to appreciate, given the magnitude of this disaster response, the possibility that medical personnel will be required to communicate for the first time with surrounding units with which they may be unaccustomed. Establishing internal and external lines of communication must, therefore, be considered of primary importance.
Anticipate Casualty Load and Types of Casualties
In 2013, an article by Missair et al. focused on traumatic injury patterns and anesthesia techniques implemented after major earthquakes.12 They reviewed 31 articles which reported on the aftermath of 15 separate earthquakes over a 30-year span between 1980 and 2010. This review did not include the Great East Japan Earthquake, but did discuss several applicable points regarding the administration of anesthesia post-disaster. They noted that the vast majority of patients that die do so in the midst of the event. These deaths are associated with traumatic brain and spinal cord injury. A separate subset will die in the immediate aftermath of the disaster, often secondary to splenic and hepatic lacerations, subdural hematomas, and pelvic fractures. Of the remaining injuries, >50% are limb injuries, with lower limb involvement exceeding upper limb involvement in >90%. This patient population has injuries amenable to regional anesthetic techniques. However, of the 31 studies reviewed by Missair et al., only eight reported on the type of anesthetic provided; 50%, or four studies, reported on the utilization of general anesthesia and 50% on the use of regional techniques.12 Concerning the Great East Japan Earthquake, K. Iinuma reported that the majority of mortality resulted from the tsunami and not from the earthquake. Thus, injuries were mostly of low acuity. Of note, however, is that the Ishinomaki Hospital received 99 casualties on the day of the earthquake, but 1251 patients on the day after, with 63 patient helicopter transfers completed on the third day.13
In a separate report published in the journal Disaster Medicine and Public Health Preparedness in 2014, Kodama et al. discussed the challenges they faced at Minamisōma Municipal General Hospital. They reported caring for 39 patients who were injured in the earthquake/tsunami, and 22 patients who were suffering from environmental exposure. Much as Missair et al. reported, one patient succumbed to shock/crush injury, two suffered pelvic fractures, two had lower extremity fractures, and two others sustained “other” fractures.14
Concerning the provision of general anesthesia to these patients, several reports (both following this disaster and previous disasters) have discussed the utilization of ketamine anesthesia as a sole anesthetic agent in the setting of austere devastated environments. Remarkably, the majority of patients that present for emergency care do so in the near aftermath (two to five days) following a disaster. During this time, medical services are often interrupted with shortages of electricity, water, transportation, and personnel. As such, ketamine, with its unique, beneficial properties, including disassociation, NMDA-receptor-associated analgesia, absence of respiratory depression to slight respiratory stimulation, and absence of significant vasodilation and hypotension, may serve as an ideal anesthetic agent. In a separate report by Missair et al. in 2010, they report on the utilization of ketamine-based monitored anesthetic care (MAC) in combination with a peripheral nerve block in >500 surgical procedures following the earthquake in Haiti.15 Unfortunately this type of detailed anesthesiology reporting in English is not readily available. However, it is easy to see that, in a patient population impacted by triple disaster, there are likely to be many benefits of regional anesthesia. The required equipment is minimal and easily portable. The technique provides significant post-operative benefits (including improved cardiopulmonary function, decreased post-operative opioid consumption, faster return of bowel function, and minimal post-operative monitoring requirements). Missair et al. in their report from 2013, address the utilization of continuous peripheral nerve catheters. Again, while providing significant and continued post-operative analgesia, these catheters ultimately require more nursing care (dressing management/oversight), as well as the utilization of specially trained personnel (both of which may be in short supply in the immediate aftermath of a disaster). It is important to note that the employment of neuraxial anesthetic techniques should be performed cautiously, with special attention to hemodynamic status. Many of these patients are dehydrated and hypovolemic due to blood loss. A neuraxial technique, with associated sympathectomy, may be ill advised.
Regarding the anticipated casualty load, it is important to consider surrounding environmental factors and operating facilities. The Great East Japan Earthquake was unique because it was the first large-scale earthquake to occur during normal business hours on a normal weekday in modern Japan.16 Furthermore, while the earthquake was associated with significant destruction, the mortality associated with the triple disaster was mainly attributed to the drownings associated with the tsunami. Other deaths were attributed to the several fires that began, including a petrochemical plant in Sendai, and a portion of the city in Kesennuma (a city to the northeast of Sendai). A fire at the Cosmo Oil Company refinery in Ichihara city remained ablaze for several days despite multiple attempts to extinguish the fire. There was also widespread destruction of homes and damage to power lines, water systems, roads, and railways. When considering the patient population in this disaster, the anesthesiologist must be prepared to assist with delivery of care to burn patients, blast and crush injuries, and patients exposed to radiation. Furthermore, emergency protocols must be developed in preparation for patients including pediatric and geriatric. In the Tohoku region of Japan most damaged by the triple disaster, approximately one-third of the patients were over the age of 65. 17
Undoubtedly, patient care delivery was impacted by the post-disaster environment, including the potential for dehydration (as water sources were disrupted and affected by the release of radioactive materials) and malnutrition (the food supply was similarly affected). Hypothermia was another factor impacting the care of the wounded from this disaster, as many were affected by the cold tsunami water. The timing of this disaster also compounded the disaster because it occurred when temperature often remained below 0 °C (32 °F). Amidst reports of snow in the region, it is easy to appreciate the tragic combination of cold temperatures, cold tsunami water, absent electricity, and destroyed homes. Therefore, the potential for hypothermia and its consequences must also be considered in preparation plans.11
Understand the Resources: Personnel and Facilities
Personnel
Because of the significant number of organizations activated in response to the crisis, and the number/types of casualties that can be expected, it is important to recognize the type of responders with which you may have to interact. Since the treaty of Mutual Cooperation and Security was ratified in January of 1960, nearly 40 000 US troops have been stationed in Japan. For this crisis, the Japanese Self-Defense Forces and United States Armed Forces were activated and deployed to the affected region within 24 hours of the earthquake. At the peak, nearly 24 000 US personnel, 189 US aircraft, and 24 US Navy vessels were located within the region in response to the disaster.2 In addition, the Japanese Self-Defense Forces mobilized 106 200 personnel, 200 rotary aircraft, 322 fixed-wing aircraft, and 60 ships.2
Several medical facilities within the Fukushima Prefecture have reported on their experiences responding to the crisis and these are discussed further in this chapter. These institutions include the Aizu General Hospital, the Fukushima Medical University Hospital, the Minamisōma Municipal General Hospital, the Red Cross Ishinomaki Hospital, and the Tohoku University Hospital. Undoubtedly, additional facilities were activated and assisted with the response to the significant casualty load (though their experiences with the delivery of anesthetic care are not easily readily identifiable in English print). Of the 170 reported hospitals in the region, 145 were fully functional in the aftermath of the disaster. Furthermore, according to a USAID report, 552 Japanese Disaster Medical Assistance Teams were activated and provided care for individuals affected by the natural disaster.18
US State Department/USAID
With a state of emergency and disaster declaration from John V. Roos, the USAID activated a Response Management Team in Washington DC and created a Disaster Assistance Response Team for deployment to Japan. They further facilitated the deployment of two urban search and rescue teams, as part of the Disaster Assistance Response Team.18
Related posts:
Chapter 5 – Inhaled Anesthetics and Draw-Over Devices in Disaster Response
Chapter 4 – Total Intravenous Anesthesia in Disaster Medicine
Chapter 14 – Considerations When Working with Children and Families
Chapter 15 – Chemical and Radiologic Exposures in Trauma and Disasters
Chapter 23 – Pharmacy in Disaster Anesthesia
Chapter 12 – High-Altitude Physiology and Anesthesia
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