the basic hospital and renal replacement therapy in the great hanshin earthquake
TRANSCRIPT
Renal Failure, 19(5), 701-710 (1997)
SYMPOSIUM PAPER
The Basic Hospital and Renal Replacement Therapy in the Great Hanshin Earthquake
Hidemune Naito, MD
Vice President Rokko Island Hospital Kobe, Japan
INTRODUCTION
The Great Hanshin Earthquake occurred on January 17, 1995, at 5:46 a.m. It resulted in 5502 casualties and 45,000 injuries. This earthquake began with a vertical shock and was triggered by active faults that extend throughout the Hanshin area, of which Kobe City is the principle city in the southern part of Hyogo prefecture, Japan. The earthquake damaged the center of this metropolitan city, and proved to be the most catastrophic event in, Japan in recent years. This natural disaster served to uncover the “structural weakness” of modem cities and the weak points of an advanced medical care system. Indeed, many issues remain to be addressed.
With regard to medical care, diagnostic procedures and treatment became useless due to the damage caused by the earthquake on advanced medicine and emergency medicine systems. It became apparent that the transportation system, designed to manage patients in such settings, could not operate effectively.
The effects of the earthquake on individual medical facilities included direct structural damage of the hospital buildings and equipment, damage to hospital systems and disruption of clinical facilities. There were new diseases. aggravation of chronic diseases, and changes in the causes of death. This was compounded by a shortage of professional medical care since providers were also directly affected by the earthquake.
Address correspondence m: Hidemune Naito, MD, Rokko Island Hospital, Vice President, 1-5-11 Koyo-cho Naka, Higashinada-ku. Kobe, 658 Japan. Fax: 78-858-1170. Presented at the International Conference on Renal Aspects of Disaster Relief, Ohrid, Former Yugoslav Republic of Macedonia, May 24-26, 1996.
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Copyright 0 1997 by Marcel Dekker, Inc
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Table 1
A Time Line After the Great Hanshin Earthquake: Changes in Treatments and Hospital Functionality Required
Maintenance of Time Phase Treatment Hospital Functionality
1-2 days Initial Triage Medical stuffs (for transportation of Emergency medicine patients and products) Management
3-5 days Transportation Selection of patients Information (to the facilities that Treatment of patients with
Emergency surgery
receive patients) disorders Transportation method
that receive patients) Transportation stuff (to the facilities
1-2 weeks Stable Acute aggravation of Examination function chronic disease Improvement of food supply
Improvement of quality of life
3-8 weeks Restoring Infection Adjustment and improvement of Stress-related illness various functions Surgery
Reconstruction of the hospital systems was required. Furthermore, 2.5 years have now passed since the Great Hanshin Earthquake and many other serious effects of the earth- quake on medical care have appeared. These are in addition to the common results on the economy and the field of architecture. Indeed, a long period of time will likely be needed to completely reconstruct the medical system. A variety of reports have been delivered concerning the effects of the Great Hanshin Earthquake on city planning, local administra- tion, building construction, and emergency medicine. There are few reports of general medical practices. This report describes the experience in our hospital, located in the center of the affected area. Included are comments on the emergency medicine in the Hanshin area, the handling of patients with chronic renal failure, the status of the casualties, and the patients with crush syndrome consequent to the Great Hanshin Earthquake.
DAMAGE TO MEDICAL FACILITIES
There were 222 hospitals and 4578 clinics in the affected area. Among the 192 damaged facilities, 15 hospitals were completely destroyed. Also, 2479 clinics were damaged. Even medical facilities that suffered only minor structural and equipment damage, as well as those that were completely or partially damaged, were isolated. This was because their utility lifelines (including electric cables, water and gas pipes, transportation systems, and telecommunication lines) had been cut. Many people who were injured by the earthquake, regardless of the nature of their injuries, went to the hospitals that were not functional, and made medical practice even more difficult.
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Damage to Dialysis Facilities
About half ( 5 8 ) of all dialysis facilities in Hyogo prefecture are located in the affected area. Among them, two facilities were completely destroyed, four were halfway damaged, 32 partially damaged, 28 sustained minor damage, and two were not damaged. A total of 2500 patients (including inpatients) and 112 patients were receiving hemodialysis and CAPD, respectively. Of these, 23 patients died from the earthquake (from crushing injuries or from fire). In addition, medical personnel who were directly concerned with dialysis medicine (approximately 960 persons) suffered in various ways. There were two deaths and four were severe!y injured. There were 88 households completely destroyed, 107 house- holds halfway destroyed, and 100 households in which there were family members injured or killed. When taken together, a considerable number of the medical personnel who worked in the attacked area suffered damage to some extent as a result of the Great Hanshin Earthquake.
Although the damage to structures and equipment was managed by emergency mea- sures, the hospital did not function effectively and there was great difficulty in providing dialysis treatment. This was because the public utilities (electricity cables, water and gas pipes, telecommunication) had been cut. It is important to focus on the materials (including electricity, water, and medical products) required for dialysis to appreciate the nature of the problem.
First, the electricity supply stopped immediately after the earthquake. It was restored within 24 h to 80% of all dialysis facilities, but complete restoration took 5 days. In many facilities, although the private electric generators started when electricity supplies stopped, they operated for only 4-6 h because fuel storage is limited by law in Japan. In addition, most private electric generators were of the cool-water type. These generators overheated after a few hours due to damage to the water supply ducts and the shortage of cool water. Looking back on the day of the earthquake, the actual length of time (24 h) it took to restore the electricity supply may not seem long, but it felt endless. During that time, the emer- gency management of those people injured in the earthquake was performed with no light, as was our contact with our inpatients.
The telephone lines were also interrupted after the earthquake. Because most telephone lines in hospital had been digitized, not only was contact with those outside the hospital lost, but the inside telecommunication system also failed after the electricity was lost. This loss of contact with anyone outside the hospital, as well as with our patients, served to heighten our anxiety because we had no knowledge of outside rescue efforts.
Later, this shortage of information during the Great Hanshin Earthquake brought on much criticism (i.e., even adjacent neighborhoods or those in the center of Japan were uninformed of the damage because the medical facilities in the quake-hit area could not send status information).
The directions given to patients in each dialysis facility undergoing dialysis on the day of and the day following the earthquake can be summarized as follows: potassium exchange resins were to be used; water should be removed under ultrafiltration; and the hemofiltra- tion for severe patients should be performed manually.
Of the 58 facilities (not including two that were completely collapsed), in 46 standard hemodialysis was restarted within 5 days, in six facilities it could not be restarted for more than 6-10 days, in two it was restarted within 1 month, and in four it could not be restarted for more than 1 month. Surprisingly, in two facilities dialysis treatment was performed with
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the aid of the water trucks driven by volunteers on the day of the earthquake. Hemodialysis was performed, although not sufficiently, with the efforts of staff and aid of the water trucks in all facilities (Figure 1).
Regarding the shortages of medical products for dialysis, one facility was short of dialyzers, three were short of saline (because these hospitals suffered relatively minor damage to structures and equipment, many patients went to these facilities). Excluding the above facilities, no shortages of the products for dialysis were reported.
Within the Basic Hospitals
We are associated with two sister hospitals, Kohnan Hospital (400 beds) constructed in 1932, and Rokko Island Hospital (309 beds) constructed in 1991 in the artificial maritime city. Kohnan Hospital is located halfway up the Rokko mountain range and Rokko Island Hospital is located on the island in the south of Kobe port, and the two hospitals stand facing each other across the east of Kobe City (where most deaths occurred: more than 1500 people died).
Kohnan Hospital has five ground floors and one underground floor and suffered no structural damages. The dormitory for nursing students was half destroyed. Six students were buried alive and two died.
On the other hand, Rokko Island Hospital is a high-rise building with 13 ground floors and two underground floors. The damage there varied depending on the direction and amplitude of the quake and varied in different layers, i.e., low, middle, and high. No patients
Restarting Days
0 0 A 1 - 2 17 3-5 0 6-10 A 11-29
30- * Destroyed
Figure 1. started and the seriously quake-hit area, in which two hospitals were completely destroyed.
The Great Hanshin Earthquake: Area of magnitude 7.2. The time when dialysis treatment
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705 Basic Hospital and Renal Replacement Therapy
were injured in either hospital, although there was destruction of sprinkler pipelines, spilled water due to the falling of the ice machines, and scattering of many goods such as the computers and the patients’ chart racks, etc. In particular, we did not suffer the type of damage that could affect hospital operations. The priority obligation of the hospitals was to ensure inpatients’ safety.
When 1 reached Kohnan Hospital at 6:10 a.m., Y decided to start the emergency medical operations after confirming the safety of the inpatients. The nurses and student nurses from the dormitories gathered in the front hall of the first floor of the hospital. Five groups of four nurses each were formed. The first group was the commanding group, the second (which included one doctor) was to discriminate between the severely and mildly injured, the third was to aid outpatients, the fourth was to care for the serious patients, and the fifth was the transportation group. All staff were instructed to put on disposable operating dress. A few physicians and surgeons who had been in the hospital on night duty were instructed to manage outpatients. Although most of the trauma patients could walk without aid, the more severely injured patients were transported by private cars or brought to the hospital carried in other people’s arms. This number rapidly increased by 7:30 a.m.
Although the triage for patients had been begun by 8:00 a.m., tasks such as clearing the airways were impossible to perform. In patients who required treatment, efforts were directed at cleaning skin for puncture of the subclavian vein, administration of steroids, and injections of analgesic drugs. I t was found later that more than 40 physicians and 120 nurses did such management. Because it was thought to be impossible to treat patients in the emergency unit only, we decided to treat patients in the dialysis unit (33 beds). By around 9:00 a.m., patients transported by ambulances began to increase. By 9:30 a.m. there were no empty beds and space on the floor of the dialysis unit was used (more than 70 patients). Patients whose treatment had finished were laid in the halls or corridor of each floor and the front hall.
This type of medical management continued until night when the relief activities decreased with the onset of darkness. During the 3 days immediately after the earthquake, 362 patients were admitted to the hospital, 92 died, and outpatient visits probably reached 1800 cases.
During the time course described above, the staff in each group did their duty. They worked until the nurses who came to the hospital later voluntarily joined the short-handed groups. This was done only after carefully obserying the status of the care and resulted in good overall management without panic. Eventually, 360 patients were admitted to Kohnan Hospital.
Regarding the diagnosis and treatment given, during the night and after the transporta- tion of patients had stopped, a balloon catheter was inserted into the bladder in the poor risk and oligouric patients. This allowed us to monitor the urine volume and the status of urine, to decide on the volume of supplemental fluid, and to detect the crush syndrome as soon as possible. We doubt that we could have performed neurosurgical operations for patients with intra-cranial hemorrhage. Actually, it was impossible even to administer drugs that de- crease the intracranial pressure because of the shortage in staff, the lack of time, and absence of appropriate space.
In the situation described above, particularly in the triage area, we noted several things. Most of the patients transported were those bruised or injured by suffocation and there were few patients with severe trauma associated with hemorrhage. Very few patients who had already died were transported. It seems that triage was performed by the general inhabitants and the ambulance teams. A change in triage levels was required according to the changing
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conditions of the medical care and because of the numbers of patients transported. Notably, the private electric generator stopped due to a lack of fuel and we had to treat patients without lights from 9:30 a.m. to 5:30 p.m.
The hospital functionality required was classified into categories including the transpor- tation phase, the stable phase, and the restoring phase, but detailed descriptions of these phases are omitted in this report (Table 1). At present, 1.5 years have passed since the earthquake, the PTSD scores in medical personal remains high, and no significant medical mistakes have occurred (Figure 2).
Dialysis Medication in the Quake-Hit Area and Acceptance of Patients
In the severely affected area, 1669 patients could not receive dialysis. Among those, 1273 patients received dialysis in other facilities located in the neighboring areas in Hyogo prefecture immediately after the earthquake, 587 patients received dialysis in the facilities in Osaka, and approximately 200 patients or more received dialysis in the facilities in other areas. The reason for the disagreement between the number of patients who received dialysis in the facilities outside of the quake-hit area and the total number of patients who were affected by the earthquake is due to the fact that one patient had to receive dialysis in multiple facilities. Patients took refuge all over Japan, excluding Osaka. Sixty percent of patients moved by their private cars or motorcycles and 14% were transported in the public emergency vehicles. Other transporting methods including helicopters and boats were also used in serious cases.
Eighty-eight percent of patients received dialysis treatment within 2-3 days (the stan- dard interval of dialysis in Japan, i.e., three times, 4 Wweek), 12% received it within 6 days, and some cases could not receive dialysis for up to 12 days.
The organizations, including the Japanese Society for Dialysis Therapy (JSDT) and the Japan Clinical Incorporated Medical Dialysis Association (JCIMD), operated as back-up
Normal
Slightly Suspected
Strongly Suspected
P T S D _________
0 5 10 15 20 25 30 35 40 45 3;;
Figure 2. year after the earthquake.
The PTSD scores of 220 medical personnel: Comparison with those 6 months and one
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Basic Hospital and Renal Replacement Therapy 707
systems for these cases. During the Great Hanshin Earthquake, both organizations imme- diately took action, including construction of acceptation systems for patients undergoing chronic renal replacement therapy and making contact with the central organizations, working as a means of contact about the volunteer activities and relief supplies, and helping individual dialysis facilities from the early period of the earthquake. Some small facilities or individual patients, however, did not benefit from these activities.
Sufficient information about the status of the hospital and refuge method was not provided to individual patients. The reasons for this, although they vaned depending on the situation of the particular facility, were the loss of hospital functionality; difficulty in contacts with their inpatients with chronic diseases because all doctors were busy with emergency patient care; the disorder of the commanding systems resulting in an insufficient spread of information to the lowest levels; the relatively long periods of time required to evaluate status because the restoration of lifelines could not be predicted; and loss of communications meant hospital staff could not contact their patients or other hospitals, nor could patients contact hospitals. This was reflected in the fact that approximately 1200 or more patients who had sheltered from the earthquake received dialysis individually in the other hospitals and clinics in Hyogo prefecture, or all over Japan, without the instructions by their original hospitals or clinics (many basic hospitals for dialysis are located in Kobe city). Nevertheless, no patients died due to insufficient dialysis treatment.
CAPD Patients During the Earthquake
There were 120 patients undergoing CAPD treatment at their home in the quake-hit area, and among them there were five patients whose houses were completely collapsed, eight patients whose houses were partially damaged, and 41 patients whose houses suffered less damage. Regarding human casualties, three patients were mildly injured. At the time of the earthquake, among 37 patients who were on dialysis with the cycler, 33 patients discon- nected the cycler because the dialyzer stopped due to the destruction of the buildings or the loss of electricity, and four patients continued dialysis by operating the machine manually. Among eight patients who used an ultraviolet sterilization device, the treatment was continued with the remaining electricity from the battery in five patients. A total of 19 emergency deliveries of dialysis materials such as dialysis fluid were required: they were transported to six patients in their houses, five patients in the shelter facilities, and eight hospitals. We thought the requests from other hospitals or clinics might be because all patients on dialysis treatment were switched to CAPD patients as a result of the loss of electricity and water, and waste water pipe damage other than running out of stocks. In cooperation with Baxter Corp., which set up the disaster countermeasure headquarters, we contacted all of our patients by the evening of the third day. The fact that all patients survived without harm was reported to each hospital or clinic. Confirmation of patients’ safety and transportation of medical products were carried out by the company as described above, which is selling CAPD products in this area. Motorcycles were used as the transportation method (for details see the previous paper). The medical products were transported from Osaka.
It took approximately 4 days to confirm the status of 120 patients even by the company that set up the disaster countermeasure headquarters in Osaka, near the quake-hit area. The dialysis centers in the affected area could not confirm the status of about 2500 dialysis patients (even medical personnel were confirmed to be safe only when they came to the
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hospital). Furthermore, we suffered a staff shortage due to the damage to public transporta- tion systems, including highways and national routes.
Crush Syndrome
The exact number of patients who developed crush syndrome during the Great Hanshin Earthquake is not known. The primary reasons for this include that patients’ conditions could not be known because of the direct damage to hospitals; the loss of hospital functionality caused by the shortage of utility lifelines and the shortage of medical person- nel even in advanced medical facilities; and individual patients could not receive enough treatment because many patients were transported to the hospital at the same time. If a patient was diagnosed as having crush syndrome, only a medical team consisting of blood purification specialists could treat the patient adequately. In our institution, about 360 patients were admitted and 92 died.
Among them, crush syndrome occurred in 18 patients (Table 2). The incidence of crush syndrome was 5.0% in inpatients and 19.2% in patients who died. The mean age of patients with crush syndrome was 40.8 ? 18.7 years and the mean compression period was 9.9 t 5.7 h. Among five patients who were severely ill and could not be transported to the hospitals in Osaka, blood purification treatment could not be performed in one patient
Table 2
Mean Age and Physical Conditions of 18 Patients with Crush Syndrome in Kohnan Hospital
Incidence
Mean age
Sex
Outcome
Compressed sites
Movementkensation disorders of the compressed extremities
Other complications
Mean compressed time
18
40.8 2 18.7 (10-72)
Male Female
Transferred to the other hospital In-hospital period Treated at our hospital
Blood purification treatment Survived Death
tower extremities (bilateral)
Upper extremities (bilateral) (unilateral)
(unilateral)
Movement (-), sensation (-) Movement (+), sensation (-)
Bone fractures Peritoneal organ injuries Chest organ injuries
11 7
13 3.2 ? 0.8 (2-4)
5 4 3 2
11 5 1 5
10 6
5 4 1
9.9 2 5.7 h
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E l Contusion F r a c t u r e Whole Body Inj Crush synd.
Thoracic Inj.
Spinal Cord Inj
B u r n s Shock
0 Others
0 Head Inj.
0 Abdominal Inj.
Ea Dehydrat ion
- Trauma 8 3 . 2 %
1 6 . 8 %
Crush synd. (18 cases : 5.0%)
Figure 3. patients.
Details of'the admitted patients who were injured during the earthquake: total of 362
due to severe hypotension. Among four patients who received blood purification treatment, three patients survived (Figure 3 ) . All patients who were transferred to the hospitals in Osaka received blood purification treatment and survived. No patient underwent an ampu- tation of extremities, although relaxation resections were performed in some cases. We were encouraged by these results achieved by the successful initial treatments, the transpor- tation system, and the treatments by the medical providers concerned.
However, all patients with crush syndrome might not have received sufficient treatment. Because there was a possibility that some patients might have died before they were diagnosed, the number of patients who developed crush syndrome may not be exact. When the numbers reported from each hospital or clinic were totaled, less than 200 patients with crush syndrome received treatment. One source reported that 360 patients with crush syndrome received treatment. However, either number is thought to be an estimate. Based on data in our hospital, the number of patients who developed crush syndrome is 978-2250, when the rates in the death cases and in the in-jury cases were used, respectively. The reasons for the difference in the number of patients who developed crush syndrome include that there is a difference in definition of injured people between public reports and the medical field, and it was estimated based on the data of only one hospital. Furthermore, 80 patients who developed the syndrome were diagnosed and treated in emergency facilities and the remainder were diagnosed and treated in facilities with nephrology specialists who handle chronic dialysis. This reflects the facts that the emergency facilities could not provide dialysis treatments to many patients at the same time and that Japanese nephrolo- gists have a highly technical method to manage crush syndrome. This also illustrates that when a disaster hits a wide range of facilities, medical professionals who have been trained in simultaneous dialysis technique will be useful for the management of patients who do not require surgical treatment.
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CONCLUSION
Naito
We have learned many things from the Great Hanshin Earthquake. First, many patients who will be injured in a disaster will be transported to all hospitals regardless of their specificity (i.e., hospitals only for renal replacement therapy or circulatory system disease) and the triage of many patients will be performed in the basic hospitals. Next, the use of facilities that receive patients on renal replacement therapy may be required for other purposes. Patients should be informed of the procedures for dialysis under emergency situations and dialysis treatments should be avoided in the hospitals in the quake-hit area as much as possible.
Regarding crush syndrome, treatment will be required in free-standing dialysis units around the affected area as well as in hospitals. Nephrologists should have knowledge about the management of this syndrome. Finally, more than 6000 people (mainly in Osaka) developed the symptoms of food poisoning caused by E. coli 0-157 and more than 70 people suffer from hemolytic uremic syndrome (HUS) in Japan (as of the end of July 1996). Based on the experience of the Great Hanshin Earthquake, doctors have opened a home page on the Internet for information on symptoms caused by E. coli 0-157 and are exchanging information on the capacities of facilities and the treatment method. This is the result of lessons learned from emergency management during the Great Hanshin Earth- quake. Future measures include establishing a communications network and reception system against epidemic diseases like food poisoning and infections as well as major disasters, and many doctors who have knowledge about blood purification treatment are required.
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