A professor at Kobe University Graduate School of Medicine, Department of Disaster and Emergency Medicine, and director of the Emergency and Critical Care Center at Kobe University Hospital, KOTANI Joji was a medical professional when the Great Hanshin-Awaji Earthquake struck in January 1995 and the JR Fukuchiyama Line derailment happened in April 2005. We asked him how it was at the time and what lessons have been learned.

What was it like at the time of the Great Hanshin-Awaji Earthquake?

Kotani:

I was actually a graduate student when we had the Great Hanshin-Awaji Earthquake. I was totally unaware that a massive earthquake might be striking the Kansai region, so much so that my immediate thought was that we’d been hit by a North Korean missile. I’d been watching a late-night program on NHK on the night before, about how Japan was now within range of North Korean missiles, and that information might have still been on my mind. My apartment building in Shin-Kobe collapsed and there was a power outage. So I only managed to find out that it had been an earthquake after going outside and turning on the radio in my car. The news reported that five deaths had been confirmed in Kobe, but seeing the damage to the city, it was obvious there were more casualties.

And then, by the time I arrived at Kobe University Hospital by car, patients were being brought in, one after another. The first-floor outpatient area had a large open space, and that was being used as a “green area” for triage. We asked the non-critical patients to stay there and await treatment, while we treated others who required more immediate attention.

Now, there was an old lady who had been pulled out of her collapsed home. She had seemed alright in the morning, so we asked her to stay in the green area. But by the time a nurse went to see her in the afternoon, she had already passed away. When we made the rounds in the green area, we found that two patients had died, including the old woman, and 13 showed symptoms of abnormally rapid breathing, a high heart rate and a low blood pressure. After discussing how it was similar to animal experiments where the blood supply to an organ was first restricted and then restored, we realized they were suffering from crush syndrome. When muscles have been crushed for a long time and then released from that pressure, highly toxic contents of dead muscle cells such as myoglobin and potassium flow into the blood and spread throughout the body, leading to, in the worst case, death.

As an emergency measure, we went to the dialysis room to put the patients on dialysis. But, like us, the doctor in charge of dialysis probably hadn’t thought of the possibility that crush syndrome patients might need dialysis at the time of the disaster. The doctor had locked the door to the room and wasn’t there. We had no choice but to use one dialysis machine that was used for animal experiments and three units that we found in the wards to perform dialysis on four patients. The remaining nine were dialyzed in a less efficient pumpless system that relied on the arteriovenous pressure gradient. We managed to transfer them to a hospital in Osaka, but afterwards we heard that they had all died.

Initial information is often incorrect

What kind of things did you learn from providing medical care in extreme conditions?

Kotani:

A mother and her elementary school daughter had died when their home had collapsed. Their bodies had been brought to the hospital separately, and so they had been placed apart from one another. The father had survived the earthquake as he had been sleeping on the second floor, and he only learned that his wife and daughter had died after coming to the hospital a while later. With tears streaming down his face, he asked us to place the bodies together, and when we carried his daughter’s body and placed her next to her mother, it made him very happy. It was a moment that taught us the importance of creating a situation so that the bereaved can accept the death of their loved ones, or in other words, preparing an appropriate setting for death.

Looking back now, what we absolutely lacked at the time was medical supplies and equipment. The relief team from outside arrived 48 hours after the earthquake. There was a shortage of testing machines, dialysis machines, and water. So this later led to the DMAT (Disaster Medical Assistance Team) program being established, and by the time the Great East Japan Earthquake struck in 2011, teams were able to reach disaster areas by Self-Defense Forces aircraft and other means.

Have you experienced other disasters as a medical professional since the Great Hanshin-Awaji Earthquake?

Kotani:

There was the JR Fukuchiyama Line derailment accident of April 25, 2005. I was working at Hyogo Medical University Hospital at the time. The first notification we received was that five people had been injured in a train and car collision in Fukuchiyama City of Kyoto Prefecture (when the actual location was Amagasaki City of Hyogo Prefecture). Then, the first drawings of the accident that we received only showed six train cars, when there were actually seven train cars in total. They hadn’t realized that the first train car had smashed into an apartment building and was hidden from sight. So, in my experience, initial information is often incorrect, and it’s important not to depend heavily on that information.

The accident happened at 9:18 in the morning. At Hyogo Medical University Hospital, we set up a disaster response headquarters and triage posts. At first, we weren’t informed of the severity of the crash, and so we told the fire department that we would accept any number of injured or sick people. The first patient was brought in at 9:50, and we dispatched a doctor car (or rapid response team) with four medical staff members, doctors and nurses, to the scene by 9:55. The hospital took in a total of 113 patients, and 99 of them were brought in during the two hours between 10:00 and 12:00. Outpatient services and scheduled surgeries were all suspended. Ten emergency surgeries were performed for patients from the accident, and then we also went back and managed to complete all of the suspended surgeries on the same day. I believe we were able to do this because we had a built up a system of cooperation on a daily basis.

Human resources should be spent on critical patients who are quiet and difficult to notice

How did you deal with so many patients being brought to the hospital in such a short period of time?

Kotani:

The emergency and critical care center doctors triaged the injured and sick patients who were being brought in one after the other. The red-tagged patients (first priority) were taken to the emergency and critical care center, the green-tagged patients (third priority) were taken to the orthopedic outpatient area, and the yellow-tagged patients (second priority), to the emergency outpatient area. The overwhelming number of patients made it impossible for the emergency doctors to use the usual triage methods, and they had to make decisions based on intuition. Later verification found that their judgment had been correct in many cases, and we subsequently named this the “First Impression Triage Method (FIT method),” publishing a paper in English. The BBC soon came to interview us and we appeared on their program, and we felt the importance of communicating our findings in English.

When examining multiple injured and sick people at once, we tend to focus human resources on milder cases as those patients can articulate their symptoms and express how they feel. But what we really should do is quickly find and help critical patients who are quiet and difficult to notice.

In the emergency treatment room, we had to make decisions on the fly when allocating medical personnel to each patient and creating space for their treatment, while it was impossible to predict how many more patients would be brought in. So it wasn’t only the emergency doctors treating the patients. The brain surgeons and internal medicine doctors also jumped in. They seemed a little apprehensive at first, but after their first few patients, they became used to it and were more efficient in their treatment.

In terms of sharing the information of patients who were brought in, we wrote down their name, age, gender, ward room, and other details on a whiteboard at the hospital entrance. It may be common now to share that kind of information with Excel files, but I feel that the analog method of writing the details down by hand, taking a photo of the whiteboard, and sending it to others is a sure and fast way to share information. The whiteboard can also be used to address the media, police, and family members.

What lessons have you learned from your experiences with major disasters and accidents?

Kotani:

Three months after the accident, I received a letter from the wife of one of the people who had died. She wanted to know what had happened after her husband had been taken to hospital as she couldn’t help feeling suspicious that he had died because his treatment had been put off for later. We invited the woman and her daughter to watch the video footage taken at the time with us. And as it showed our many staff members doing their best to treat the man, the woman and her daughter started to cheer him on, saying, “Come on, Dad.” It was as if we had traveled three months back in time and were sharing the day of the accident. Watching the video helped them accept his death. The two of them cried and said that his death had been inevitable and that they saw how he had done his best to survive.

It made me see that understanding how and why someone died allows the bereaved to accept the death of their loved ones. It was a reminder of the importance of setting up a team to take and keep video recordings in this way.

Meanwhile, some of the medical personnel who treated the patients at the time developed PTSD (post-traumatic stress disorder) from the guilt of being unable to save patients. I believe the intense circumstances took a toll on their minds and bodies. It reminded me of the importance of providing care for medical staff also.

Are there any other lessons that should be applied in the future?

Kotani:

When we sent the doctor car to the accident site, the residents and factory workers nearby were already helping the injured. They had laid out many of the patients on the street, but they had also placed wet towels on their faces, which is I guess a Japanese style of nursing patients. But when we’re trying to provide medical care, this makes it difficult for medical staff to assess which patients are in critical condition.

Then again, many of the injured were laid out at the entrance of a building that was away from the accident site, perhaps in an attempt to get them out the noise and chaos. But we need to have patients in places that are easy to notice, because there is the possibility we won’t notice that they are there, and we are too late to treat them. In fact, just as we were leaving the site, we discovered a patient who had been laid out in the shade of a tree a short distance away and had already expired. So we really need to raise awareness among the public who may be treating the injured in the initial stages.