the great hanshin-awaji earthquake and the problems with emergency medical care

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Renal Failure, 19(5), 633-645 (1997) SYMPOSIUM PAPER The Great Hanshin-Awaji Earthquake and the Problems with Emergency Medical Care Takashi Ukai. MD Emergency and Critical Care Medical Center Osaka City General Hospital Osaka, Japan ABSTRACT One of the world’s largest port cities, Kobe and its viciniv, \vas hit by a so- called “shallow und direct hit” type earthquake with a magnitude of 7.2 on the Richter scale in the early morning of January 17, 1995. A total of 6308 people were killed and upproximately 35,000 people were injured. About 400,000 houses rind buildings were more or less damaged, and electriciq, water; and city gas supply were suspended in a wide area. Medical facilities were also greutly damaged. Thti destruction of roads, highways, bridges, and railways made it diflcult ,for people to move within this urea. Extraordinary trafic congestion occurred. Telephone lines were disconnected or overloaded. Thus. the modern hea1th.y urban lives that the people had taken for granted were lost in a moment. Emergency responses to the disaster ,fell behind. Transportation of severely injured patients away from the disaster area to the non-affected area was not smooth because of the interruption of communica- tions and traflc congestion. The scope of the damage from the disaster; types of injuries, chizracteristics of the victims, problems with emergency medical care encountered in this disaster; and revisions of countermeasures executed after the disaster are reported. Address correspondence ro; Takashi Uka 1, MD, Head, Emergency and Critical Care Medical Center, Deputy Director, Osaka City General Hospital, 2-13-22, Miyakojimahondori Miyakojima-ku, Osaka 534 Japan. Presented at the International Conference on Renal Aspects of Disaster Relief, Ohrid, Former Yugoslav Republic of Macedonia, May 24-26, 1996. 633 Copyright 0 1997 by Marcel Dekker, Inc. Ren Fail Downloaded from informahealthcare.com by McMaster University on 10/27/14 For personal use only.

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Page 1: The Great Hanshin-Awaji Earthquake and the Problems with Emergency Medical Care

Renal Failure, 19(5), 633-645 (1997)

SYMPOSIUM PAPER

The Great Hanshin-Awaji Earthquake and the Problems with Emergency Medical Care

Takashi Ukai. MD

Emergency and Critical Care Medical Center Osaka City General Hospital Osaka, Japan

ABSTRACT

One of the world’s largest port cities, Kobe and its viciniv, \vas hit by a so- called “shallow und direct hit” type earthquake with a magnitude of 7.2 on the Richter scale in the early morning of January 17, 1995. A total of 6308 people were killed and upproximately 35,000 people were injured. About 400,000 houses rind buildings were more or less damaged, and electriciq, water; and city gas supply were suspended in a wide area. Medical facilities were also greutly damaged. Thti destruction of roads, highways, bridges, and railways made it diflcult ,for people to move within this urea. Extraordinary trafic congestion occurred. Telephone lines were disconnected or overloaded.

Thus. the modern hea1th.y urban lives that the people had taken for granted were lost in a moment. Emergency responses to the disaster ,fell behind. Transportation of severely injured patients away from the disaster area to the non-affected area was not smooth because of the interruption of communica- tions and traflc congestion.

The scope of the damage from the disaster; types of injuries, chizracteristics of the victims, problems with emergency medical care encountered in this disaster; and revisions of countermeasures executed after the disaster are reported.

Address correspondence r o ; Takashi Uka 1, MD, Head, Emergency and Critical Care Medical Center, Deputy Director, Osaka City General Hospital, 2-13-22, Miyakojimahondori Miyakojima-ku, Osaka 534 Japan. Presented at the International Conference on Renal Aspects of Disaster Relief, Ohrid, Former Yugoslav Republic of Macedonia, May 24-26, 1996.

633

Copyright 0 1997 by Marcel Dekker, Inc.

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634 Ukai

INTRODUCTION

Japan is located on the Pacific Volcanic and Seismic Limb and as a result, has been struck by a number of large earthquakes and volcanic eruptions in the past. In this century alone, 39 major earthquakes have hit the Japan archipelago. With some exceptions, most have occurred along the borders of tectonic plates. The Pacific Ocean and the Philippine Sea tectonic plates are creeping under the Eurasian and the North American plates on which the Japan archipelago lies. The tectonic plate seismic theory explains why Japan has been struck by so many earthquakes. In recent years, middle to large-scale earthquakes have frequently occurred in and around the northern island of Hokkaido.

Several years ago, on the basis of a statistical study, some seismologists warned that the Kinki Area (with some exceptions in the middle west part of the main island Honshu) is one of the most likely areas to be hit by a big earthquake. There are countless numbers of active faults in this area that over the long history of the earth have left evidence of ground movement. In spite of these warnings and the presence of active faults, people living in Kink Area, especially in Kobe and Osaka, did not believe their area might be the target of a large-scale earthquake because it has not been hit by one for about 400 years.

The most devastating quake in this century in Japan was the Great Kanto earthquake of 1923, which assaulted Tokyo and Yokohama with magnitude of 7.9 on the Richter scale and killed about 140,000 people. The main cause of death in that disaster was bums due to the extensive fires that followed the earthquake. Most of the houses were made of wood at that time. Thereafter, disaster prevention measures such as building construction standards in Japan have been developed aimed at this scale of earthquake. The building construction code itself was amended several times after the Great Kanto earthquake and the established standards were related to the intensity of Kanto earthquake. Today, building construction standards in Japan are said to be the most strict in the world. In spite of the severe damage to buildings and highways in the Mexican and Northridge earthquakes, none of the Japanese architects anticipated such extensive destruction of buildings as was seen in the Great Hanshin earthquake. On the contrary, some experts said that such destruction could never happen in Japan because the construction standards were much more stringent than those in Mexico or in the United States.

AN OVERVIEW OF THE DAMAGE

At 5:46 a.m. on January 17, 1995, the southern part of Hyogo Prefecture, which is the middle west of Honshu and is a part of Kinki Area, was hit by an extraordinarily large earthquake. The epicenter of the quake was about 14 km under the northern tip of Awaji Island, which is about 20 km from the center of downtown Kobe (Figure I), and the magnitude was 7.2 on the Richter scale (1).

The most severely damaged area was the middle to the east part of Kobe, Ashiya, and Nishinomiya. Since this region is called the Hanshin region, the earthquake was named The Great Hanshin-Awaji Earthquake. This area is one of the most developed urban areas and together with Osaka, it forms the second largest metropolitan region in Japan. The Hanshin area is developed on a narrow plain belt and is sandwiched between the Rokko Mountains to the north and Osaka Bay to the south. This is a very popular residential area with its mild climate, beautiful scenery, and convenient transportation facilities. Main traffic arteries,

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Emergency Medical Care 635

Figure 1. Epicenter and the major area affected by the Great Hanshin-Awaji Earthquake.

national routes, highways, and several railways that connect the eastern and the western parts of Japan run through this narrow plain.

The final death toll by this earthquake was reported at 6308 including the secondary deaths that were apparently related to the earthquake. About 35,000 people were injured. At the peak point, 316,678 people were evacuated to 1153 temporary shelters such as schools and other public buildings. Roads were severely damaged in 9408 places and 318 bridges collapsed. Accordingly, traffic was severely restricted in the affected area. The earthquake completely destroyed 101,233 houses and about the same number were cate- gorized as half-destroyed. Fire following the earthquake destroyed 7456 houses (Table I ) . The main destruction occurred in old wooden houses with heavy tiled roofs. The collapsed houses blocked the roads and obstructed rescue and relief activities (Figure 2). Reinforced concrete buildings that were built according to the old construction code were also damaged (Figure 3 ) . Notably, the buildings that were built by the revised construction standards of 1981 did not suffer serious damage.

Damage to the roads, bridges, and railways was also severe, especially the damage to the elevated highways, which made highway traffic impossible and left the roads under the elevated highways blocked (Figure 4).

Damage to the railways occurred in more than 90 places (2). The elevated railway of Shinkansen (with the bullet train that usually runs at speeds of 250--300 km/h) was also disabled (Figure 5) . If the earthquake had occurred an hour later, several trains would have derailed and tumbled from the elevated railways. This would have resulted in thousands more dead and injured.

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636 Ukai

Table I

Damage by the Great Hanshin-Awaji Earthquake

Number of deaths 6308 Number of injured 34,900 Number displaced 3 16,678

Damage to bridges Damage to roads

318 9408

Damage to buildings Completely destroyed houses 101,233 Half-destroyed houses 107,269 Partially destroyed houses 182,190

Destroyed other buildings 3120 Destroyed public buildings 549

The most extensive and uncontrollable fire broke out after the earthquake in the Nagata ward of Kobe. The area has the highest population density in Kobe. Because water was not available from fire hydrants, firefighting was extremely difficult. Although fire brigades from Osaka, Kyoto, Nagoya, Wakayama, and even from Tokyo helped the Kobe city fire brigade, it took more than 30 h until they succeeded in extinguishing fires using sea water.

The characteristic of this disaster was that the quake hit the most developed urban area directly, and that it disclosed the fragile nature of this sophisticated, modernized human lives in the urban area.'Water was unavailable in 1.27 million households, city gas service

Figure 2. A completely destroyed wooden house can be seen blocking the road.

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Figure 3. A damaged reinforced mncrete apartment house

was cut off to 845,000 households, and the electricity was cut off to 1 million households. Approximately 285,000 telephone lines were disrupted and, in addition, the number of calls coming into the affected area rose to 5 0 times more than usual, resulting automatically in the activation of switchboard circuit protection mechanisms. Thus, lelephone calls to the disaster area were almost impossible to make on the first, second, or even the third day.

Figure 4. Collapsed Harishin Highway.

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638

Figure 5. Collapsed railway of the Shinkansen (Bullet Train Line)

Ukai

Millions of people who had used public transportation services everyday lost their means of transport. Accordingly, a tremendous number of people began to move in their cars soon after the earthquake to evacuate from the disaster area or to ascertain the safety of their families, which resulted in the ultra-heavy traffic congestion on the undamaged roads. This caused delays in the arrival of rescue personnel and relief goods from the neighboring cities and delays in the transportation of severely injured patients from the disaster area to the non-affected area.

Damage to Medical Facilities

Damage to the medical facilities was also a serious problem. Among 180 hospitals in the southern part of Kobe, 4 hospitals were completely destroyed and 12 were so severely damaged that they needed extensive repairs. Only 4 hospitals suffered no damage. Out of 1809 clinics, 101 were totally destroyed, 92 were half destroyed, and 563 were partially destroyed (Table 2 ) . Kobe City West Hospital, which was the key hospital in the west part of Kobe, suffered serious structural damage and its fifth floor collapsed like a pancake. Forty-six patients were trapped (Figure 6).

Not only were the hospital buildings damaged, but the facilities within the hospitals were also disrupted. In the hospitals in southern Hyogo Prefecture, about 40% of operating rooms could not be used. Sterilization was impossible in about one-fifth of the hospitals because disinfecting rooms were unusable. Sophisticated medical equipment such as magnetic resonance imaging apparatus, computed tomography scanners, x-ray machines for angiography, and autoanalyzers were damaged in many locations (Figure 7).

In addition, electricity, tap water, and gas supply were cut off to the hospitals. To make matters worse, the water reservoirs on the roof of the hospital buildings and their connec- ting pipes were broken and all the stored water poured out. As the water level of the

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Table 2

Damage to the HospitaUClinic Buildings by the Earthquake

Hospital Clinic

Totally destroyed 4 (2.2%) 101 (5.0%)

Half-destro yed 12 (0.7%) 92 (5.1%)

Partially destroyed 13 (7.2%) 153 (8.546)

Need extensive repair 81 (45.0%) 410 (22.78)

Need minor repair 66 (36.’7%) 764 (42.256)

No damage 4 (2.2%) 289 (16.0%)

Total 180 (100%) 1809 (100%)

reservoir decreased, the water in another reservoir in the basement was automatically pumped up to the broken reservoir, and the water supply was soon exhausted. Without water, water-cooled home power plans could not work.

Attendance of hospital medical personnel was severely affected. Some were injured and some lost their family members. Almost all of them lost their means of transportation. Attendance rate of medical personnel at the hospitals on the first day of the disaster was greatly reduced. Only 58.4% of the doctors, 35% of the dentists, 44.2% of the nurses, and 31.0% of the clerical employees were present.

Figure 6. Pancake-type structural damage of the 5th floor of the Kobe City West Hospital.

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Page 8: The Great Hanshin-Awaji Earthquake and the Problems with Emergency Medical Care

640 Ukai

Figure 7. Destroyed x-ray tube in the Kobe City Hospital.

Thus, the hospitals in the middle of the disaster area became non-functional as modern hospitals. None-the-less, many injured and deceased patients continued to be transferred to those hospitals that were severely damaged. This was particularly true in the first 6 h after the disaster.

Prehospital Care

Communication and command systems in the local government were also severely damaged and the initial response of the government was poor. The local government officers, policemen, and firefighters were themselves affected in one way or another by the earthquake. Even the satellite radio communication system on top of the Hyogo prefecture government building did not work for several hours. Therefore, several hours were neces- sary to mobilize self defense forces into the disaster area for the search, rescue, and relief activities. Prehospital health care workers, usually ambulance crews and paramedics, could not work properly, because they had to work on extinguishing fires or after the dispatch of the ambulances, they were detained by citizens to assist in rescue efforts. Because of the

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over-whelming number of emergency calls, ambulance dispatch centers of fire departments stopped responding. On-site triage was almost impossible because there were so many damaged sites.

CAUSES OF DEATH AND TYPES OF INJURIES

Dr. A. Nishimura of Kobe University inspected 3651 death certificates in Kobe and analyzed the causes of death. According to his study, the most frequent cause of death was asphyxia due to direct compression of the chest or from being buried under the debris of houses. The second most frequent cause of death was severe crush injury. Protracted deaths by organ failure and emaciation or cold were few (Table 3). Frequent types and sites of injuries among the patients admitted to Hyogo Prefectural Nishinomiya Hospital were fracture of the spine and spinal cord injury, crush injury, fractures of the clavicle and the extremities, pelvic fracture, and chest trauma such as lung contusion, pneumothorax, and hemothorax. Multiple trauma was not uncommon, but abdominal organ injuries were rather rare (Table 4). Those who were trapped under the heavy debris of houses and suffered serious abdominal organ injuries might not have been able to survive for several hours and might have died before extrication.

Apart from the small injuries such as lacerations, contusions, sprains, and minor

Table 3

Cuuse of Deaths of the Victims of’ the Great Hanshin-Awuji Earthquake

(Analysis of Inquest Records by D,: A. Nishimura)

Cause of Death Number (%)

Asphyxia

Crush injury (chest, whole body)

Bum and C O poisoning

Contusion, crush

Head trauma

Shock (incl. hemorrhage)

Neck injury

Chedabdominal organ injury

Organ failure

Coldemaciation

Unknown

Others

Total

1967 (53.9%)

456 (12.5%)

444 (12.2%)

308 (8.4%)

124 (3.4%)

74 (2.0%)

63 (1.7%)

62 (1.7%)

15 (0.4%)

6 (0.2%)

116 (3.2%)

16 (0.4%)

365 1

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Table 4

Type and Place of Injury of Hospitalized Patients at the Nishinomiya Hospital

Single Trauma Multiple Trauma ~ ~~

Fx. spine, spinal cord injury

Crush injury

Fx. clavicle/extremities

Fx. pelvis

Chest trauma

Fx. skull

Peripheral nerve injury

Urogenital organ injury

Traumatic asphyxia

Contusion

Laceration

Total

18 Fx. pelvis and extremities 6

11 Fx. spine and extremities 3

10 Chest and abdominal trauma 2

8 Crush injury and chest trauma 2

5 Crush injury and extremities 1

3

3

2

1

9

6

76 14

fractures that required massive efforts of surgeons in the middle of the affected area, traumatic asphyxia, spinal cord injury, and crush syndrome were the three prominent injuries of the disaster victims.

Few traumatic asphyxia cases showed vital signs on arrival at the hospitals. Regarding spinal cord injury, the fate of the paralyzed limb had almost been destined regardless of the emergency operations. Therefore, the most important group of the injured who needed careful attention of physicians in the early phase was crush injury, especially the patients with crush syndrome that might develop shock, hyperkalemia, acute renal failure, serious arrhythmia, and sudden cardiac arrest.

According to the surveillance study of the 6107 hospitalized patients in the first 15 days after the disaster, 372 suffered from crush syndrome. The mortality rate of those with crush syndrome was 12.1%. This was more than twice that of the other trauma patients. Acute renal failure developed in 122 of these patients and 108 were treated with some form of blood purification procedures. Non-oliguric renal failure was seen in 14 patients.

PROBLEMS OF EMERGENCY MEDICAL CARE

Destruction of Local Medical Services and Overwhelming Numbers of Patients

As was mentioned, the medical facilities in the disaster area suffered severe damage and in addition, they were crowded with a large number of emergency patients and dead bodies and their families. On the other hand, few patients were transferred to hospitals in the non-

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Emergency Medical Care 643

affected area in the first 12 h because telecommunication was cut off and traffic conditions were extremely bad.

Delay in Transporting the Injured and Dispatching Relief Medical Teams

Under normal circumstances, it takes about 1 h to drive from Kobe to Osaka by car. However, after the earthquake, several hours were necessary-even by ambulance- because of road destruction and heavy traffic congestion. This was one of the reasons for the delay in the transfer of severely injured patients.

Tertiary emergency medical centers in Osaka, which were only 10--20 km apart, suffered little damage by the earthquake and they could receive patients with any injury and could offer sophisticated medical services. However, in the first 12 h, only lhree patients were transferred to the 11 tertiary emergency centers in Osaka.

Several hospitals in the non-affected area thought of dispatching, medical relief teams into the disaster area immediately. However, they either could not make contact with the local authority of the affected area or they were not accepted because of lack of informa- tion. They waited until the request for relief was made and as a result, lost crucial time for the necessary immediate relief activities. Osaka City General Hospital (OCGH) succeeded in making contact with Ashiya City Hospital, which was still in chaos on the evening of the day of the earthquake. OCGH sent trauma surgeons to Ashiyn City Hospital with ambu- lances. They triaged the in.jured people who were in the lobby and the wards and took 16 severe patients to OCGH by the next morning. Most of the patients transferred were suffering from crush syndrome.

Patient Transportation by Helicopter

In Japan, the use of helicopters for transportation of emergency patients was not common except in some prefectures with remote, isolated islands. After the earthquake, because traffic conditions were extremely bad, helicopter transportation of emergency patients proved to be very effective and valuable. Travel from Kobe to Osaka took only 15 min by helicopter, whereas the trip required 5-10 h by land. Helicopters from various organizations, including fire departments, prefectures, self defense forces, maritime safety agency, and private companies were mobilized and were able to transport 172 patients in the first 19 days. Although many helicopters had been sent to Kobe in the early phase, only one trauma patient each was transported on the first and second day. The information that the helicopters were available was not properly transmitted to the medical staff in the affected area. In addition, there were several legal and nonlegal restrictions for the usage of helicopters and the authorities could not respond flexibly at first. Therefore, only a limited number of hospitals could use helicopters effectively.

LESSONS LEARNED

Search and Rescue System Should be Reinforced

Prior to this time, search and rescue operations were the responsibility of the fire and police departments of the affected local government. Assistance from rescue forces from other autonomies or self defense forces could be started only in response to an official request for relief from the governor of the affected prefecture. However, because of the

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extensive chaos and shortage of manpower, the affected government lost the ability even to ask for external relief in the first several hours. The Fire Defense Laws and Self Defense Forces Laws have already been amended so that external assistance is available without an official request from the governor but by the judgment of the local head of autonomies.

Hospital Damage and Lifeline Disruption

Many hospitals suffered serious damage and could not function properly as modem hospitals. Even if the building structure was well maintained, hospitals could not provide medical services properly without electricity, water, and gas. Of these so-called lifelines, the loss of water was the most serious matter. It is apparent that hospitals should have a well for their exclusive use. The advisability of having roof-top water reservoirs and the use of a water-cooled home power plant should be reconsidered.

Information Transfer System

Telecommunication to and from the affected area was almost impossible in the first 3 days after the earthquake because of the extent of the mechanical damage and the over- loaded switchboard circuits. We had been relying too much upon the telephone. Although an emergency radio communication system was available in the Hyogo prefectural govern- ment, this did not work in the early phase. Multiple methods of communicating should be available to the appropriate government offices and to the medical facilities themselves. In some parts of Japan (Nagoya and Kushiro), new radio-communication systems now connect medical facilities directly.

Long-Distance 'hamportation of Emergency Patients

Due to the heavy congestion of the traffic, land transportation of critically ill patients between distant hospitals was almost impossible. The only effective solution to this problem was the use of helicopters. However, the fact that helicopter transportation of injured patients was necessary only emphasized the fact that the system in place could not effectively work in the face of real emergencies. Only a limited number of the hospitals could effectively use the helicopters. Recently, a small study group was organized to examine the problems of long-distance and long-time transportation and are considering the transportation of emergency patients by helicopters under normal circumstances. The Ministry of Autonomy has created a budget to distribute tens of helicopters for emergency use and has started to develop new guidelines for the utilization of helicopters for the transportation of emergency patients.

Designation of First-Aid Facilities

On the first day of the disaster, a number of injured citizens visited fire stations and asked for the treatment of small wounds or transportation to the hospitals, However, few person- nel were left in the stations and they could not treat these people properly. On the other hand, many doctors and nurses found it difficult to get to their hospitals because of the traffic problem. If they could have come to the fire stations designated as the first-aid posts in their neighborhoods during the early phase, precious professional medical resources could have been effectively utilized.

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Education on Disaster Medicine

The laws and systems related to disaster emergency relief have been extensively reviewed during the last 15 months in Japan. Several laws and acts have been amended to include some of the suggestions made above. But what is important is not only the amendment of laws but the recognition that people-including medical professionals- must be prepared for disasters. The Disaster Committee of the Japanese Association for Acute Medicine sponsored a seminar on disaster medicine for the first time in Japan last March, and the Ministry of Health and Welfare is planning to sponsor a series of seminars on disaster medicine. We are making efforts to improve disaster preparedness and response in Japan.

REFERENCES

1.

2.

Fujimoto M: Urban Shock. The Japan Times Special Report. The Great Hanshin Quake, The Japan Times, 1995. pp 9-11. United Nations DRA-Geneva: The Great Hanshin-Awaji (Kobe) Earthquake in Japan. The Earthquake, On- Site Relief and International Response. United Nations. 1995.

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