Chapter 3. Development of Disaster Relief Activities with Ishinomaki Red Cross Hospital (RCHP) as a Hub Hospital

Transcription

1 Chapter 3 Development of Disaster Relief Activities with Ishinomaki Red Cross Hospital (RCHP) as a Hub Hospital

2 Great East Japan Earthquake and Tsunami Chapter 3 Chapter 3 Development of Disaster Relief Activities with Ishinomaki Red Cross Hospital (RCHP) as a Hub Hospital This chapter describes medical relief services provided at the venue of Ishinomaki RCHP, MIYAGI. Medical relief activities in ISHINOMAKI are characterized by the extensive number of its medical teams deployed for long periods and, more remarkably, through cooperation with medical institutions other than JRCS within/outside the region. In this context, this whole chapter introduces the medical relief services for Great East Japan Earthquake and Tsunami (GEJET) as they clearly show the characteristics of the services. Figure 3-1 Profile of Ishinomaki RCHP Situated in the northeastern part of the coastal area of MIYAGI (Relocated from the coastal site and newly constructed in May 2006) 26 clinical departments, 402 beds (10 beds for Critical Care Center) No. of staff: 901 (as of March 1, 2011) Main fanction certificated as below, etc. Disaster Relief Core Hospital (designated in 1997) Regional Emergency and Critical Care Center (established in 2009) Regional Medical Association Hospital Designated Regional Cancer Centers and Hospitals Miyagi Maternal and Perinatal Care Center Designated Hospital for Postgraduate Clinical Training Designated Hospital for Category 2 Infectious Diseases Facility for organ donations following brain death Ishinomaki medical service area (ISHINOMAKI, HIGASHI MATSUSHIMA, ONAGAWA): Approx. 220,000 residents, surrounding area: approx. 100,000 residents, Total: approx. 300,000 residents [Damage status in ISHINOMAKI (taken from the side of Hiyoriyama Park) ] 1. Damage due to the GEJET (1) Damage Status in ISHINOMAKI The earthquake was significant in scale with a tremor of an intensity of 4 upper lasting about 160 seconds, as well as 2 jolts of intensity 6 lower. 1 The quake subsequently caused a massive tsunami that devastated the coastal regions. In the 40 minutes after the earthquake occurred, a very high tide of about 8.6 meters was observed at AYUKAWA, ISHINOMAKI. 2 In ONAGAWA, adjacent to ISHINOMAKI, Onagawa Municipality Hospital situated some 16 meters above sea level was inundated with about 2 meters of water. The tsunami swept the buildings across coastal lands, leaving behind debris. In the central part area of ISHINOMAKI, 73 km2 of the site (or 13.2% of the town or approx. 30% of the plain) was flooded. Ishinomaki municipal government office, Firefighting Head office, Fire House, Police Station, etc., were within the flooded areas. Water did not recede around Ishinomaki municipal government office for 3 days, which was temporarily isolated. Furthermore, 20 fires occurred in the territory of the Ishinomaki Firefighting Headquarters'. In KADOWAKI and MINAMIHAMA, situated to the west of Kitakami River, a large-scale fire occurred immediately after the tsunami and kept burning for 2 days. The number of fatalities in ISHINOMAKI, HIGASHI MATSUSHIMA and ONAGAWA reached 5,224, and the number of missing persons was 744 (as of February 28, 2013). It is also estimated that some 42, 000 people took refuge at more than 300 evacuation center in ISHINOMAKI in the initial phase of the disaster. Figure 3-2 Human suffering in ISHINOMAKI (Unit: Number of casualties) No. of fatalities Number of Direct cause Indirect cause Total of death of death missing persons ISHINOMAKI 3, , HIGASHI MATSUSHIMA 1, , ONAGAWA Total 4, , Source: Prepared by Damage Situation of the GEJET, MIYAGI (1) Earthquake and Tsunami Warning for a Disaster Zone (2011) prepared by the Meteorological Agency (2) 2011 off the Pacific Coast of Tohoku Earthquake (it was renamed GEJET later), prepared by the Extreme Disaster Management Headquarters, Cabinet office (17:00, December 27, 2011). 94

3 Amid this turmoil, every single medical institution in the Ishinomaki area, except for Ishinomaki RCHP, suffered severe damage. Only 5 institutions in the area were available to provide medical services immediately after the earthquake. Ishinomaki Municipal Emergency Medical Clinic and Ishinomaki Municipal Hospital (206 beds for general patients) which had played a central role in primary and secondary emergency care were also unavailable to provide medical services. Ishinomaki RCHP was left as the only available hospital to respond to primary to third level emergency care services, resulting in a situation in which patients in the area were concentrated on the hospital. Figure 3-3 Comparison between the flooded areas of GEJET and the Tsunami Hazard Map in ISHINOMAKI A Map by Geospatial Information Authority of Japan Ishinomaki Tsunami Hazard Map Source: Report of the Committee for Technical Investigation on Countermeasures for Earthquakes and Tsunamis Based on the Lessons Learned from the 2011 off the Pacific coast of Tohoku Earthquake by the Cabinet Office (2) Damage to Ishinomaki RCHP a. Damage to the Building/Equipment, etc. (a) Building Following the unprecedented damage in the entire the Ishinomaki area, Ishinomaki RCHP suffered minor damage to its building and machinery, including cracks on the road in front of the entrance, precision instruments for testing broken in exam rooms on the first floor, documents scattered from the open shelves of the fifth floor ward staff station without any major damage to the building and machinery. As background to this and as mentioned later, the hospital was relocated and newly constructed as a seismic structure to prepare for protecting the local community from a disaster at a site 4.5 km inland from the coastal zone in (b) Elevators The hospital has 11 elevators, including 5 units designed to include a generator backup system. These units allowed additional setting up with a monitoring device. However, all of the hospital's 11 elevators stopped working due to the power outage. And from a legal point of view, once an elevator stops, it is not allowed to be restarted until a nationally certified technician (elevator test technician) checks it to ensure safety. As the elevator company employees in charge of ISHINOMAKI were also victims of the disaster they were unable to conduct repair work for the elevators. On the evening of March 13, a testing staff member from the elevator company came to the hospital from Tokyo, although he came to the conclusion that they would stop the elevators as they are considering possible aftershocks. As a result, required to take the stairs to carry both patients and meals. It required a certain number of peoples to carry the patients up the stairs (each wheelchair took 4 people to carry it up, and a stretcher required 6 ). Food and medicines were carried in bucket brigade fashion, including some that were relatively heavy. The work was extremely difficult because the stairs were also too narrow to carry patients and supplies. From March 14, 8 elevators came into operation, the responsibility for which was shouldered by the hospital (3 elevators remained stopped until March 21 when the failure of their seismoscopes was repaired). (c) Hospital Information System, etc. With an in-house power generator, the hospital information system (HIS) for electronic charts or medical affairs accounting worked normally. However, the only available systems were those connected to emergency power outlets by way of the in-house power generator; and the following devices were available for service. One room (out of 3) for general radiography Three portable (out of 3) radiography units One CT unit (out of 2) One MRI unit (out of 1) One X-ray fluoroscopy unit (out of 2) Two angiography units (out of 2) Chapter 3 Development of Disaster Relief Activities with Ishinomaki Red Cross Hospital (RCHP) as a Hub Hospital Great East Japan Earthquake and Tsunami 95

4 Great East Japan Earthquake and Tsunami Chapter 3 PACS (an image database system where medical video diagnostic devices such as CT and MRI are connected to computers via a network, and test images are electronically stored, searched and analyzed) was available for use. However, the images that were taken could not be stored or delivered for several days after the disaster; there was no choice but to handle film input. b. Damage to Lifelines (a) Electricity Although the power outage lasted 2 days, the power switched to an in-house power generator, then there was no major disruption until it was restored on March 13. In order to reduce the risk of power outages, we received power from 2 transformer substations of the electric power company so that we could use a standby power system even when the main line was off. On March 13 at 12:00 the main line was restored and the standby line was restored on March 19. Two in-house power generators were installed on the roof, while an uninterruptible power supply (UPS) was available for important units such as the operation room, switching to in-house power generator settings without a power outage. The heavy oil to operate the generator for 3 days was stored (20,000 liters; 1,500 kw/h - 1,000 kw/h/day). However, because insufficient fuel remained to continue, we requested Ishinomaki municipal and Miyagi prefectural governments and JRCS Headquarters to supply heavy oil. On March 14, a private tanker from NIIGATA supplied 8,000 liters of heavy oil. Electricity was prioritized for medical purposes and some lighting equipment. Blood tests were only provided for emergency cases, while radiographic examinations were available, including X-ray photography, CT and MR images. PCs were also available, the staff could send test results and instructions for drug prescriptions to the related Departments via the ordering system and provide medical, testing and accounting services as usual. (b) Water and Sewage The water system is divided into 2 types; drinking water and general services water. In addition, 2 water receiving tanks had been installed for each line to spread the risk. Water outages lasted 5 days due to this earthquake disaster. The amount of clean water stored was only 190 t, a half-day s worth of stock (as instructed by the Health Center). People were alearted to save water throughout the hospital and asked the Waterworks Department of the City to supply water via the community wireless system. A water truck (10 t) arrived from ISHINOMAKI in the afternoon of March 12, and a private water wagon of 20 t capacity came to supply water. On a preferential basis, the city government supply was restored at 17:00, March 16. The amount of water for general use (mainly for restrooms) was 470 t, 3-days worth of stock. Artificial dialysis, requiring 10 t a day, was carried out using the water for miscellaneous use. As the stock of general service water was running out, 400 t of water was transferred for firefighting into the water tank from March 13. There were 3 water tanks for Firefighting with 600 t of water in total usually stored; therefore, it was possible to leave 200 t in the event of a fire even when 400 t of water was used for general service purposes. Sewage functions remained because there was an inland sewage disposal plant in the western district of the city (cf. the sewage disposal plant of the eastern district was damaged by the tsunami). Inside the hospital, the sewage functions were maintained although subsidence of the land had caused part of the sewage pipe around the entrance to incline in reverse. (c) Utility gas To prepare for an earthquake, the city gas was supplied using supposedly quake-resistant, low- and medium-pressure gas pipeline networks. However, Ishinomaki Gas Co., the supplier, located close to the port, was affected by the tsunami and immediately discontinued supplying utility gas in the wake of the disaster. On March 23, Ishinomaki Gas borrowed a mobile gas generator from Shizuoka Chubu Gas, installing it in the premises of the hospital. We brought in technicians from a boiler company in OSAKA to have it remodeled by midnight on March 23 so that it could supply low-pressure gas using a boiler for a midpressure gas network. Liquid gas was vaporized using several tankers and employing 2 men for 24 hours, and was then directly delivered to the hospital. With the low-pressure gas supplied, it was temporarily restored from March 24 and fully restored on April

5 (d) Medical Gas A stock of medical gas (oxygen) for 2 weeks was available, although it was used 30 to 40% higher than usual. While we were unable to get in touch with the supplier, a gas tanker carrier came from AOMORI and AKITA on March 15 to provide us with a supply. Until returning to normal operation on April 11, we filled liquid oxygen tanks with liquid oxygen six times (more times were needed due to the unstable supply; a single time filling did not make the tank full). Liquid nitrogen was filled one time. Nevertheless running short of the small medical gas cylinders, local companies were also suffered in affected area so that the headquarter supported to collect them. (e) Communication As shown in the following table, fixed-line phones and cell-phones were not usable, and community wireless systems and satellite-based mobile phones were only available for service. PHS phones were available within the hospital. Type Fixed-line phones Cell phones Satellite-based mobile phones Situation Both of the two NTT base stations were affected and their landline had been disconnected for 10 days. It was restored in the evening of March 20. Not connectable some 2 hours after the earthquake. Staff from DoCoMo Shop Ishinomaki Branch, under contract to Disaster Recovery and Support Services, brought us 10 cell phones on the day of disaster. However, they had connection problems even though they had priority telephone links in a disaster. Therefore, we requested them to establish a base station on March 16. After negotiations with the Sendai Branch, a station was set up, standing on high ground, close to the hospital and the connection was restored. Connectable. However, it interrupted the voice communication due to inaudibility. We had borrowed one set of satellite-based mobile phone from DoCoMo Shop Ishinomaki Branch before the disaster, and one more set was delivered on the disaster day. (Later, we borrowed additional sets). Multi-Channel We had agreed to use this system at the time of Access (MCA) disaster with our neighboring hospitals but it was not Radio System 3 available in this time to connect with the hospitals that had been affected by the disaster. Community Wireless System PHS Internet The Community Wireless System directly connected to the municipal government was available for service. A Self Defense Force (SDF) Advance Unit, unable to arrive at City Hall, also used it when they came to the hospital. The general switchboard, connectable to the PHS handy nurse call system, was available within the hospital. Not available for 10 days. c. Human Suffering There were no injuries to about 1,000 staff who were working inside the hospital on the day of the disaster. There were also no injuries or fatalities to some 380 inpatients in the wards or about 100 outpatients in the outpatient departments. On the other hand, 32 staff lost their relatives within the second degree (9 were missing), 383 staff had their homes completely or partially destroyed, partially damaged, or flooded above the ground floor level. 2. Activities inside the Hospital (1) Response in the Acute Phase by Timeline Order a. Situation Immediately after the Disaster Occurred At 14:50, immediately after the disaster occurred, the Ishinomaki RCHP Headquarters for Disaster Control (HDC) was established. Then a lifeline check was completed in some 20 minutes. At 15:03, Dr. Kaneta, HDC Assistant Director, assessed the situation as Level 3 considering the size of the disaster, which was informed via in-hospital broadcasting. The Disaster Response Manual of the hospital assumes 3 levels depending on the degree of the disaster. Level 3, the highest level, refers to a situation in which medical services in normal times become unavailable, and all of the staff have to be engaged in disaster response for the long term. At 15:12, all surgical operations were stopped in the operating room. To classify patients by priority for treatment, a Green area (patients with mild conditions or F/ U) was established around the front entrance of the waiting hall in the lobby, and a Yellow area (patients with moderate conditions or those on stand-by treatment) in the waiting room for outpatients in the lobby. A Red area (patients with serious conditions/ first priority for treatment) was established in the Regional Emergency and Critical Care Center so that the patients might be easily transported by land or air ambulance crews from a heliport site. A Black area (for the deceased) was established in the Rehabilitation Department at the end of the 1st floor hall. Because it was as cold as a midwinter day, the location of the triage post (to classify patients according to their condition) was changed to around the entrance of the hospital. The triage area had been set up by 3:25p.m. and staff were assigned at 3:43p.m. The parking lot Chapter 3 Development of Disaster Relief Activities with Ishinomaki Red Cross Hospital (RCHP) as a Hub Hospital (3) MCA Radio System refers to a communication system for professional use that allows many users to share a multiple frequency band (phone line channel) of the 800 MHz range for the efficient use of radio waves. It has resistance to interference and need no certificate for use. Great East Japan Earthquake and Tsunami 97

6 Great East Japan Earthquake and Tsunami Chapter 3 for use as a temporary heliport was also immediately closed to all vehicles and was made ready to serve as a heliport. b. Timeline of the Day of the Disaster At 3:23p.m. the first patient with a mild injury was carried to the hospital. An ambulance vehicle from Ishinomaki District Wide Area Firefighting Headquarters Guard Division carried the first patient classified into the Red area at 4:20p.m. As one of the ambulance crews said, ISHINOMAKI is severely damaged by the tsunami. The staff members voluntarily came in one by one, reporting the same. However, the rescue operations did not go smoothly with 2 out of 3 ambulance service groups for Firefighting being affected by the disaster, and 12 out of 17 ambulance vehicles in ISHINOMAKI swept away. The number of ambulance transported patients to the hospital ended up being 9 vehicles on the day of the disaster. At 4:25p.m. the in-house broadcasting system provided the instruction that those on the day shift should not go home, but just stand by. At 6:37p.m. the leaders of each Department at HDC were convened and shared information with the instruction to divide the teams into 3 shifts so they could take a rest because an avalanche of patients was expected from the next day. At 8:00 p.m. assuming the situation was to become prolonged, it was instructed that two thirds of the staff may go home because our emergency state will be lifted by 8:00a.m. the next morning. However, the staff found on their way home that roads and bridges were covered with debris and water, and many of them returned to the hospital. Furthermore, bus and taxi services were unavailable for people supporting inpatients, as well as for outpatients; thus they remained in the hospital as returner refugees. While the whole city was engulfed in darkness due to the power outage, an increasing number of people came on foot or by car to the hospital, which was the only building lit up due to the lighting provided by the in-house power generator. At 9:43p.m. the Ground SDF arrived. based on a request for disaster relief operations, an SDF Advance Unit was leaving for Ishinomaki City Hall from Tagajo Army Post, TAGAJO. However, they were unable to reach the City Hall due to the flooding and dropped by at Ishinomaki RCHP where the community wireless network was installed. And then for 4 days they stayed at the hospital, communicating with the municipal governors to provide relief activities. At 2:26a.m. on March 12, the first rescue team arrived from Hachinohe RCHP, followed by a medical team from Nagaoka RCHP at 3:30a.m. [Staff gathering at Ishinomaki RCHP HDC from each Department] c. The Next Day and Thereafter On the day following the earthquake, 17 medical teams (13 JRCS medical team and 4 DMAT teams) came together from across the nation. However, the roads were covered with debris and land subsidence was found in the roads, which did not allow the medical teams to travel for long distances. On the other hand, in order to cope with the increasing number of patients, some teams provided in-hospital support services for the patients, rather than traveling from shelter to shelter to provide medical care in the neighborhood. On the second day after the disaster, an Emergency Fire Response Team joined forces with other rescue teams, and the number of ambulance for transporting patients to the hospital surged to 109. In the 48 hours after the disaster, the number of serious cases that were transferred to the Red area totaled 115. Some people suffered from tsunami pneumonia, which resulted from swallowing saltwater mixed with oil and dirt. Many elderly people had aggravation of their chronic condition. To cope with the increasing number of inpatients, we increased the number of beds by up to 50. On the day following the disaster, 779 patients, and on the 3rd day, 1,251 patients were transferred to the hospital, which at normal times has 60 emergency patients a day on average. Helicopters from the SDF, the Coast Guard and the Police were waiting in the air, which numbered 63 on the 3rd day alone. There was a deluge of patients inside the hospital. Running out of food in storage, we managed to eat the food and 98

7 supplies sent from the Headquarters and brought in by the medical teams. What had worsened the situation was an increase in number of people who, other than patients, visited the hospital for non-medical services, to ask for drugs, to find their families, or for the purpose of using the toilet, shelter, etc. And once they were in, many of them wanted to stay in the hospital to take refuge. If this situation had continued, it would have become more difficult for the hospital to accept severely affected patients. Thus, the hospital set up a guidance desk to ask the purpose of their visit prior to triage, this was a Triage before the Triage Service. The Green area was moved to deru established by the JRCS medical Center at the front entrance outside. (2) Triage Area Established a. Triage Post The triage post, where patients are to be diagnosed and firstly classified into the Red, Yellow, Green, or Black areas after examining their physiological condition, was set up at around the entrance of the hospital and later moved to the front entrance outside the building. Doctors, interns, nurse managers, nurses, clinical engineers and administration staff were engaged in the triage practice in rotation every 3 to 4 hours. On the first day, there were not many patients, approximately 100. However, on the day following March 12, we dealt with close to 800 cases for triage. At the triage post, patients were classified by color according to their priority for treatment, tags with the appropriate color coding were attached to their wrists, and they were guided to each area. At the reception desk the staff always served to provide dedicated IDs by recording the reference ID for an outpatient on the surface of his/her triage tag and issuing a disasterrelated clinical records. (There were so many patients in the Green area that specific reference numbers were unaccountable.) By using the electronic medical record system, the number of patients were managed subsequently in order to maintain and store medical records, including tags and charts, and to enable the Medical Affairs Department to easily handle the documentation work. Approximately 12,000 disasterrelated clinical records were generated up to the end of March. As mentioned before, only 9 ambulance services would be provided on the day of the earthquake disaster; however, the number surged on the next day and thereafter, peaking at 150 vehicles on March 14 with 689 vehicles in total over the 7 days after the disaster. These transportation services also included those provided by the SDF, or by helicopters, and the staff were busy responding to them. Over the one week after the disaster (as of 14:46, March 18) we had accepted 4,181 patients. In these circumstances, the Ishinomaki Wide-Area Fire Department accepted/handed over ambulance vehicles, handed over duties, recorded, and liaised with DMAT. It deployed two emergency medical technicians until April 20, two coordinators resided at the heliport in order to support safety management around the clock. [Hospital staff providing medical services in the hospital lobby flooded with patients] b. The Red area Patients triaged to the Red area numbered only 17 on the first day, but the number peaked at 74 on the next day, adding up to 283 patients in total for a week after the disaster. Exogenous diseases accounted for a majority of the 48-hour (from the disaster) patients and, remarkably, many cases showed hypothermia in which rectal temperatures (anal temperature measurement) range below 35 degrees Celsius. This was because many people had been soaked in snowy seawater for many hours, or were wet through and waiting for help in places without any heating. Many people suffered from so-called tsunami pneumonia, chemical pneumonia, that resulted from swallowing saltwater mixed with foreign objects and oil after the tsunami carried away ships and machinery, while there were few external injury cases. It was about 48 hours after the disaster that some changes were noticed in the condition of the patients who had been brought in the hospital; the number of exogenous disease cases (i.e., external injuries, Chapter 3 Development of Disaster Relief Activities with Ishinomaki Red Cross Hospital (RCHP) as a Hub Hospital Great East Japan Earthquake and Tsunami 99

8 Great East Japan Earthquake and Tsunami Chapter 3 hypothermia, etc.) decreased and the number of endogenous disease cases increased. This is presumed to be because elderly people, as well as patients suffering from diabetes and heart disease, lost their medicines and their health condition deteriorated. The number of emergency patients, even for those in a chronic phase, did not decrease. There were some 100 patients in the hospital as compared to 64 a day on average before the disaster. In total, 2,290 patients had been brought in for 3 months. Many of them were transferred from disaster shelters. As for the breakdown by symptom, there were many cases of pneumonia, digestive organ disorders, and cardiovascular diseases. Those suffering from infections or dehydration also came to us over a period of one to two months. Potentially lethal patients had been brought in to the Red area one by one. The staff members focused on making empty beds available for incoming patients, moving mildly affected patients to the Yellow area, or to the hospital wards once the treatment methods for them were identified. In the 48 hours after the disaster, 118 patients triaged to the Red area included 64 (54.2%) hospitalized patients and 40 (33.9%) patients transferred to Yellow and Green areas. Later on, the staff members identified patients (supposedly) transferrable by the Regional Medical Liaison Office and collected information on their potential destinations, prepared a list of patients, and had emergency physicians in charge of the Red area arrange transfer methods for the patients. c. The Yellow Area The Yellow area was for moderately ill patients who are conscious, verbally responsive when asked their name, or otherwise those who are waiting for hospitalization. This area was established in the outpatients room on the first floor. Due to the large number of patients, the medical teams joined forces for in-hospital support. For one week after the disaster the patients numbered 1,050, many of whom did not need to be hospitalized and were able to go home as soon as the treatment was over. However, many people had lost their homes they could return to or their vehicles. There was a concern that, if the present situation were to continue, many patients would stay inside the hospital, disrupting our care for severely ill patients. Therefore we talked with the City Hall officials for the arrangement of bus services to the disaster shelters. The patients transferred on the second day also included elderly people requiring nursing care who were at their homes or nursing facilities when caught in the tsunami, and patients receiving HOT (home oxygen therapy) at their homes. They were brought into us due power outages and medical device breakdown. The so-called disaster challenged needed more space for medical care and medical transportation. In view of the situation, we established an Outpatient Treatment Room in the Outpatient Chemotherapy Center, a special department available for the addition of beds as designated in the Disaster Response Manual. For 12 days from March 12 to March 24 when the medical transportation service was completed, the Outpatient Chemotherapy Center with 15 beds for medical services accepted a peak number of 47 patients daily, which was 2 to 3 times the number of beds. With regards to the breakdown of patients, the proportion of HOT patients accounted for approx. 50%, and those requiring nursing care for some 30%. After March 19, electricity was restored; and the number decreased with people getting home or using medical transportation. After April 4, the services were handed over to JRCS medical teams gathering across the nation for support. The Yellow and Green areas were integrated to form a Yellow-Green area. d. The Green area The Green area was for patients with mild illnesses/ injuries who were able to walk. Initially the temperature was cold and the area was set up in the Waiting Hall, immediately close to the front entrance of the hospital. The disaster day saw only 47 patients arriving. On the second day they numbered 552, and on the third day 1,037, many of whom stayed inside the hospital. In order to prioritize severe patients triaged to Red and Yellow areas, There was no choice but to set up deru at the front entrance, moving the Green area from the Waiting Hall inside the hospital to outside the building. On March 23 the deru was withdrawn. On April 4 medical teams took over the services of the Yellow area, which was integrated with the Green to Yellow- Green area. 100

9 e. The Black area The Black tagged corpses lay in repose for a short duration in the Black area. A team consisting of 10 professional staff, including doctors, nurses, clinical psychologists, laboratory technicians, rehabilitation staff and administrative staff was organized to provide services on a round-the-clock basis. They had to face the sorrow of the bereaved, which was a grueling duty in both mental and physical terms. Most of those transferred to Black area were chronic pulmonary aspergillosis (CPA) cases (dead-on-arrival). The day of the disaster saw 2 patients, the second day 11, and the third day saw the largest number of transferred patients, 23 patients. On around the fourth day we began to see patients who had died of pneumonia. Until April 5, the day of the withdrawal, 131 corpses had been brought in, including 70 bodies accepted by their families and funeral service agencies, and 61 bodies transferred to a designated morgue facility. The Rehabilitation Room at the end of the first floor was used as the morgue room. They were supposed to be placed for a short duration until being accepted by the funeral service agencies; however, the duration was prolonged because the agencies themselves were affected. The designated morgue room was sunny with higher temperatures, which generated an offensive odor. With an increase in the number of corpses, the morgue room on the basement floor of the hospital was also used. The road was also so flooded that ambulance service teams were unable to carry the corpses to the gymnasium, designated as a morgue, brought the dead bodies to the hospital. The number of corpses went on increasing as those who died in the hospital wards were added. On March 14 we managed to carry the 17 corpses that had been placed in the hospital into the morgue of the City Hall. On March 15, the crematory services were restored. Figure 3-4 Triage results for the week after the disaster (until 14:46 of March 18) The Green area 2,769 patients 66% The Black area 79 patients 2% The Red area 283 patients 7% The Yellow area 1,050 patients 25% (3) Responses by Each Department a. Dialysis Treatment Center In Ishinomaki Medical Service Area, all dialysis treatment centers except the Ishinomaki RCHP were affected by the disaster. Therefore, the hospital accepted all of the 540 patients on dialysis therapy in the area. In 2008, the Disaster Networking System for the Ishinomaki Medical Service Area with the related facilities in the Ishinomaki Area, sharing information on the number of beds, etc., had already established to cooperate with each other in the event of a disaster. On the day following the earthquake, clinical engineers from 2 institutions came over to the hospital, attending to the patients. On the second day, the peak number, 124 patients were accepted. Dialysis patients were provided with therapy for 3 hours, 2 times a week instead of for 4 hours, 3 times a week in normal times; and with 5 courses instead of 3 courses daily. To secure materials and drugs necessary for the dialysis was the key to controlling the flood of patients. Dialysis materials for 240 occasions, assuming 2 courses for 4 days had been prepared and ones on a regular service a periodic basis just delivered for the day. However, it was difficult to obtain more because all effective means of communication were cut off and the wholesalers were affected by the disaster. In order to procure the materials and drugs, the hospital made contact with the manufacturers and wholesalers by using satellite-based mobile phones, and requested the JRCS medical teams to bring the materials and drugs needed for dialysis as relief supplies. In addition, a facility in SENDAI accepted about 40 patients, and other facilities in HOKKAIDO, YAMAGATA, etc., accepted those who were able to stay for a long duration. RCHPs across the nation provided support to the Dialysis Treatment Center. They included, as hemocatharsis therapy, assembling/priming the blood circuit, assistance for needle puncturing/blood returning, preparations for devices and drugs in use, etc. This assistance allowed the Center staff to take a temporary break from providing the services. b. Outpatients Receiving HOT Therapy and the HOT Center Patients on home oxygen therapy (HOT) cannot survive without using such medical devices as a respirator, oxygen/transfusion pump for the home, etc. Once these become unavailable due to a power outage or other causes, the situation is lethal and those patients will die Chapter 3 Development of Disaster Relief Activities with Ishinomaki Red Cross Hospital (RCHP) as a Hub Hospital Great East Japan Earthquake and Tsunami 101

10 Great East Japan Earthquake and Tsunami Chapter 3 within a few hours. While Ishinomaki RCHP normally deals with 88 patients, it is estimated that there were approximately 200 patients in the entire Ishinomaki area. (Many people were expected to die due to the shortage of oxygen, or because they were unable to move and escape.) On the earthquake disaster day nine patients came to the RCHP for oxygen. Those who visited the hospital to ask for oxygen were triaged to the Yellow area, guided to the Waiting Hall in the hospital. Designated as a treatment area in the event of a disaster, this area has a medical gas system to supply oxygen installed in the wall with medical power supplies. We gathered the patients at a spot with the central plumbing system for the oxygen service. It was expected to have a flood of patients coming in who were unable to use their oxygen concentration devices at home due to the tsunami and prolonged power outage. So on the next day, March 12, a HOT Service for Outpatients was established temporarily to provide oxygen at the Chemotherapy Center and other hospital rooms. There were 26 patients on March 12, and 29 patients (the peak number) on March 13. On March 16, a HOT Center was established at the Rehabilitation Center with 50 oxygen condensers borrowed. Because only up to 30 amperes were available, 30 oxygen condensers were only set up. This was not enough, therefore the patients ware asked to directly lay blankets on the floor between the beds in a fourbed room of the ward or Chemotherapy Center. Owing to malnutrition and the poor environment, 20% of the patients had exacerbation. On March 25 electricity was restored. The patients who were able to get home was asked to move to other hospitals, thus transferring 29 patients. On this day, there was no patients on home oxygen therapy. c. Midwives Center In regards to obstetrics and gynecology department or midwives facilities, all of the four institutions in Ishinomaki area, except Ishinomaki RCHP, were affected by the disaster. Thus, expectant mothers were concentrated in the hospital. Sixty-one pregnant women in the first 2 weeks, and 110 over one month were delivered. At normal times there are some 50 deliveries a month; thus, it was more than double. On the night of the disaster day, a Midwives Center was established and integrating outpatient services and the ward were under the control of a Maternity Ward Manager. At normal times they may be discharged from the hospital in 5 days after a spontaneous delivery, but the number of days was changed to 3 days. Devices used for delivery were also in short supply, which were borrowed from hospitals in the Sendai Medical Service Area. At the impact phase milk and diapers were running out as well, but they were supplied by the related manufacturers. To arrange and control those relief supplies was also one of the major services. On March 16, ten nurses and eight midwives were dispatched through the JRCS Headquarters. The service was provided on a rotation basis until May 14. In total 105 nurses were deployed for the ward's support and care services, and 100 midwives for delivery support. The hospital also arranged for obstetricians to be available on a weekly rotation for some 2 months until September. d. Responding to an Increase in the Number of Pneumonia Cases After the disaster, the number of patients suffering from endogenous diseases, mainly pneumonia, increased enormously. For 2 months from March 11 to May 9, those emergency patients hospitalized in Respiratory Medicine numbered 316, 3 times the total for the whole of the previous year (105 patients). They included 190 pneumonia cases, accounting for 60% of the total. There were three possible causes of pneumonia as follows. [A view of the HOT Center] Aspiration pneumonia: Insufficient oral care due to the water outage may increase bacteria in the saliva, which flows into the trachea and triggers aspiration pneumonia. Tsunami pneumonia: Caused by swallowing sludge in the seawater, oil generated from vehicles and machinery, and chemical substances from factories. Dust pneumonia: Bacterial pneumonia caused by inhaling dust containing chemical substances generated decades ago in sludge brought by the tsunami. 102

11 Asbestos was also a concern as well. Under cosponsorship with the Fit Test Workshop, the Ishinomaki RCHP organized a Special Local Seminar on the Use of Respiratory Protective Equipment (Protective Gear) for Professionals Engaged in Disaster Restoration/ Rehabilitation Work two times in May and June, when demolition and the removal of damaged houses started on a full scale for disaster rehabilitation. Participants in the seminar included volunteer doctors and nurses belonging to local NPOs, nurses from Ishinomaki Municipal Hospital affected by the disaster, health center staff, local government site managers, company managers in charge of debris removal, Firefighters, nursing teachers of high schools adjacent to debris-collection points, RCHP related staff, etc. Figure 3-5 Acceptance of Patients Requiring Nursing Care e. Response by the Hospital Pharmacy (a) Response to the Acute Phase Pharmacies in ISHINOMAKI suffered from major damage; out of 97 pharmacies in total, 38 were totally destroyed, and 31 were half destroyed. The Ishinomaki Pharmacist Association did not function at all. In these circumstances people who lost their medicines due to the tsunami flooded into the Ishinomaki RCHP from the early morning of the day after the disaster. Thus, the Pharmacy Department began providing medical services at about 7:30 a.m. Immediately after the earthquake, 3 staff were assigned to the triage area, and 1 staff at a temporary pharmacy established inside the hospital. The appropriate prescription for drugs was issued regardless of whether the patient had a primary care doctor (PMD). In order not to disrupt other medical services in the hospital, we established a Temporary Prescription Counter with a LAN cable with a length of 50 meters connecting three PCs for ordering prescriptions online at the front entrance. However, as the temperature dropped significantly, the Counter was moved inside the hospital from the second day, with two more PCs to alleviate congestion. The day after the disaster, the duration of a prescription for medication was limited to 3 days. On the disaster day and the following day, medicine stocks for about 3 days, and borrowed some from 4 general pharmacies around the hospital if insufficient inventory was in stock. Due to the power outage, medications that should be stored in a cool place were also stocked in the Pharmacy Department, such as insulin from the 4 general pharmacies around the hospital, for delivery to the patients. Drug stocks were running out for the first three days because the wholesalers were affected and due to the lack of gasoline; however, the necessary medicines were provided by sending out requests nationwide. Specifically, these supplies were from the Headquarters, Tohoku University Academic Society, Miyagi Local Government, private doctors, business entities, etc. Medical teams across the nation, including JRCS. The staff members were on three-shift work schedules from March 13 to 16, and on two shifts from March 17 to April 3. Because the Ishinomaki RCHP staff alone was not sufficient to meet the shortage of personnel, pharmacists were delegated from Tohoku University, Japan Pharmaceutical Association, Japanese Society of Hospital Pharmacists, Sendai RCHP, and JRCS Headquarters. Pharmacists from JRCS medical teams joined forces as well. As of August 15, 1,203 support staff in total had been assigned. (b) Mobile Pharmacy, Team Melon-Pan The next problem was how to deal with patients in the disaster shelters. The identified problems were shared with the Ishinomaki Pharmacist Association; We want to deliver medicines to patients with chronic diseases who are not able to visit us, the drugs brought in by the medical teams are not sufficient to cover the range of chronic diseases, etc. In this context, the concept of pharmacist teams traveling from shelter to shelter to provide medicines started. The Disaster Relief Act was to be applied to normal medical services, as well as disaster medical relief, covering free medications until the end of June. A Team Melon-Pan consisting of doctors from Ishinomaki RCHP, pharmacists and the Pharmacist Chapter 3 Development of Disaster Relief Activities with Ishinomaki Red Cross Hospital (RCHP) as a Hub Hospital Great East Japan Earthquake and Tsunami 103

12 Great East Japan Earthquake and Tsunami Chapter 3 Association staff was organized to provide mobile pharmacy services, traveling from shelter to shelter to provide medicines. The Team Melon-Pan delivered prescribed drugs provided by Ishinomaki RCHP to chronic disease patients at the disaster shelters. The team was named due to their hope to deliver joy to people like a mobile bakery that sells melon-pan (a melon-shaped and melon-flavored bread roll). At the most difficult time after the earthquake disaster, day after day those melon-shaped bread rolls just before their best-before date had been delivered as meals for the staff, which also contributed to the name. they also provided guidance on medication, collected information on the hygiene conditions in the disaster shelters, produced Okusuri-Techo (Drug Passbooks) that are indispensable when handing over information on a patient's drugs to other medical institutions. They produced Okusuri-Techo that covers the history of a patient's prescription drugs for all of the patients at the disaster shelters so that the passbooks might be used for those without prescription records or who were running out of medication. Figure 3-6 Outline of the services provided by Team Melon-Pan Participants: 143 staff Ishinomaki RCHP pharmacy staff (20), and doctors (3), JRCS Support Team (99), General pharmacies around the RCHP (5), Japan Pharmaceutical Association supporters (16) Total mileage: 15,880 km No. of disaster shelters visited: 161 sites (683 sites in total) No. of drug prescription sheets: 4,273 [Team Melon-Pan] The Team Melon-Pan traveled from shelter to shelter, obtaining information on the patients in order to write their prescriptions. They prepared the drugs according to the prescriptions at the Ishinomaki RCHP, delivering them to the disaster shelters including those prescribed by the medical teams. In some cases the medical teams dropped by the hospital to pick up the medicines and then brought them to the disaster shelters. The medical teams, including JRCS Medical Team, brought medical prescription sheets from their hospitals whose formats were not common. Then the medical teams and the Team Melon-Pan integrated the formats of the prescription to prevent omissions in the necessary records, and to alleviate stress when preparing the drugs. From April, three to four pharmacists and one driver (hospital staff) started traveling from shelter to shelter in the city every morning and evening. Because there were too many kinds of medicines for chronic diseases including diabetes, they produced and took the prescription to the hospital and delivered the prescribed drugs. Not only delivering the drugs, f. Psychosocial Support Services (a) Responses to Patients in the Acute Phase and affected people The earthquake dealt a heavy blow to people not only physically but also mentally. As Ishinomaki RCHP does not have a Psychiatry Department, psychiatrists from outside the hospital provided medical services. In cooperation with local government officials, JRCS Psychosocial Care staff also pitched in until the patient care could be provided by psychiatrists. Ishinomaki RCHP has Psychology Department with one clinical psychologist and two clinical development psychologists in service. On the disaster day, immediately after the HDC was established, they went on duty in the whole hospital on rotation, caring for those in a panic state, with hyperventilation syndrome, strong anxiety, etc., including among inpatients and outpatients staying inside, and their attending family members. On and after the second day, patients triaged to the Yellow and Green areas included those who lost their house or family due to the tsunami, or those who were at a loss searching for their family members in vain, those who kept crying or had difficulty in maintaining verbal communication, etc. In the same way as other patients, mental disorder patients were transferred to Ishinomaki RCHP, the only functioning hospital for psychiatric patients; we asked their doctors 104

13 to generate documents on their information and handed them over to public health nurses and local government officials. Before long psychiatrists from Tohoku University Hospital came to provide support, responding to the bereaved and assisting to carry corpses in the Black Area. (b) Responding to the Staff The HDC focused on psychosocial care, establishing a Refreshing Room for staff personnel at the reception room and deployed psychiatric doctors. On March 16, a Refreshing Room was established next to the Hospital Director s Room. For four months until July 18, footbaths and hand massage services, active listening, etc., were provided by support teams, mainly JRCS Psychosocial Support Teams. These services were used by 134 people in total from March 16 to 31, 252 in total in April, 104 in total in May, 20 in total in June, 45 in total in July; adding up to 555 in total. Also, those who hoped to receive psychiatric care from the beginning, or claimed chronic sleep loss and strong anxiety were referred to psychiatric doctors providing assistance. (c) Responding to Patients and Disaster affected populations in chronic stage As for psychosocial care support many organizations cooperated in providing services. On March 14, the JRCS Psychosocial Care Support Teams joined forces for the program, and 38 teams with 365 staff in total provided services until September 1st. The services provided mainly included support for the evacuees. The teams periodically visited three to five shelters that seemed to have many patients with psychosocial problems. They also sometimes dropped by the shelters that did not have enough support from the local government. They also responded to individual cases that had been requested by the Joint Medical Teams, referring them to psychiatric doctors as needed, and were engaged in social welfare management services including life support. They also helped supporters (local government officials who managed the disaster shelters and the supporting volunteers) and hospital staff. The psychiatrists received support from Tohoku University Hospital, providing medical services and drug prescriptions at the Emergency Medical Department in the hospital and the disaster shelters. Subsequently, from April 7, each psychiatrist from RCHPs across the nation pitched in for in-hospital support on a weekly shift rotation. Until October 14 they dispatched 30 staff in total, providing medical services to about 140 patients. Mental health care for the hospital staff was also provided in cooperation with industrial doctors. After the in-hospital needs decreased, two staff of the Clinical Psychology Department shared information with public health nurses and travelled from shelter to shelter to provide medical care with the Psychosocial Support Team. In cooperation with the JRCS Psychosocial Support Team and the Joint Medical Team they visited patients in the community (at disaster shelters or their houses) if necessary. (d) Cooperation with Local Communities We maintained close communication and cooperation with local government officials, public health nurses who were familiar with the local situation, and Clinical Psychology Department. Psychiatric Medical Teams of Tohoku University Hospital, JRCS Psychosocial Care Team, and the public health nurses of ISHINOMAKI and HIGASHI-MATSUSHIMA at Ishinomaki RCHP as a hub hospital gathered to hold a psychosocial care support joint meeting where they reported on what they had done and what the disaster victims needed, discussing mental consultations for the disaster victims, and taking up active listening requests and challenges, etc. The meeting was held once daily in the acute phase of the disaster, once every two days from late March, once a week from April, and once every other week from August. After September, psychiatrists in the Ishinomaki Medical Area, Miyagi Welfare Office joined forces for a monthly meeting, Joint Meeting on Psychosocial Care Support for the Ishinomaki Medical area. g. Food Procurement/Provision Following the earthquake, a Level 3 was declared and the use of the kitchen was restricted. Gas was not available either, and water had to be saved for medical use on a priority basis. The emergency food that had been stocked for disasters was served. The elevators were not working and it was hard to deliver the emergency food, water pet bottles that had been stored in the second basement floor to each ward of the hospital. Although there was no food stored for the staff, the Chapter 3 Development of Disaster Relief Activities with Ishinomaki Red Cross Hospital (RCHP) as a Hub Hospital Great East Japan Earthquake and Tsunami 105

14 Great East Japan Earthquake and Tsunami Chapter 3 supplier of the hospital store was supposed to provide merchandise to them in times of an emergency, so they received sweet buns and sweets sold at the store. (In fact, the staff were in service at their workplaces and had no time to eat; only a small portion of them managed to have time to eat them). 150 kg of rice in stock was boiled over 2 days using cookers from midnight on the day of the disaster, preparing rice balls throughout the night. On the following day, boiled rice was available. However, it was impossible to use plates; the amount available for each staff was one rice ball at breakfast, lunch and dinner. From March 12, relief and food supplies were delivered from RCHPs across the nation and the Headquarters, etc. Because those food items would expire in another 2 days at the most, food items were delivered within the expiration dates to the patients, and those just before or with ambiguous expiration dates to the staff. Subsequently, a disconnection in the communication lines prevented us from ordering more food (in two weeks food delivery was available). JRCS medical teams were asked to bring the necessary supplies. On March 16 water services were restored, which allowed them to cook food materials. However, on March 17, the relief supplies that had been periodically provided stopped, leaving food stocks (except rice) only for another 2 days. On March 18, the hospital asked for the public to help them cope with food shortages in an interview televised live. Following this, relief supplies began to be delivered from across the nation, which enabled them to solve the inventory problem of the shortages on March On April 12 about 80% of the meal services were restored and by May 11 they were fully resumed. hospital for an interview, repeatedly broadcasting that they were reporting from Ishinomaki RCHP, the only functioning hospital in ISHINOMAKI. In using media, many people got info about the hospital. The shortage of medicines, fuel and food supplies that was talked about was written in articles, resulting in more support over time. On March 18, after a dietitian claimed, the remaining food will last only one day in a live televised interview, many supplies were sent from the neighborhood and across the nation. These PR activities may have sometimes helped patients and affected people. The hospital staff asked a local FM radio station, Radio Ishinomaki, to make an announcement that oxygen was provided to patients receiving HOT therapy. The whole of the radio station of Radio Ishinomaki was affected by the disaster and yet they managed to continue broadcasting services using a microphone on an apple crate at the top of Mt. Hiyori, where a transmission station was located. Before the disaster it was talked about cooperation at the time of an emergency, and so their 10:30 radio program was available to provide information for local people on medical services at Ishinomaki RCHP, disease prevention and other precautions. h. Public Relations For this earthquake disaster, the Ishinomaki RCHP was willing to receive media exposure. However, immediately after the disaster no mass media asked for an interview. This was because the hangar for helicopters used for media coverage at Sendai Airport was swept away by the tsunami. The first reporter that visited us was from Kyodo News Enterprise. After the interview, an article was produced, titled, As If in A Field Hospital, which was delivered through local papers. On March 14, a popular anchorman and TV station crew came to the [Providing information at a press conference with a flood of news reporters] (4) Transportation and Transfer Support for Patients and Evacuees Immediately after the disaster, the Ishinomaki RCHP accepted all patients who flooded to the hospital, including those who had completed receiving medical care, no place to go after being released from the hospital, returner refugees. On March 13, It was begun to sort the people lying on the floor into patients and evacuees. Acute patients who needed treatment at the hospital were transferred to 106

15 medical and nursing facilities, and people who visited the hospital for evacuation purposes were transferred using a shuttle bus connecting the hospital and the disaster shelters. On the other hand, people seeking information on the safety of their family members still came to the hospital. a. Transportation of the Patients Among nearby medical institutions affected by the disaster, Ishinomaki RCHP, a critical emergency center, was the only hospital in the area that had accepted many patients. However, the number of beds of the hospital was limited to 402 beds plus an additional 50 temporary beds. The problem was how the hospital could maintain its functions as an acute-phase hospital. Thus, transportation service was started for the patients. An interview survey was carried out to identify patients who were able to transfer to another hospital. However, it was hard to deal with many patients who were unable to say their names, those who had no family left to care for them, or whose triage tags were removed in the hospital. Because communication tools were unavailable, the staff visited medical institutions and nursing facilities within the range of a 30-minute walk, and tried contacting the hospitals in remote areas using satellite-based mobile phones for the purpose of asking whether or not they could accept our patients. However, their reactions were not very favorable. From March 13 to 15 we managed to transfer only 16 patients. From March 16, emergency physicians was invited in the Red area integrate and control the list of transferable patients for the arrangement of transportation methods, which allowed the staff to efficiently identify the potential patients transferable to other hospitals. That Tohoku University Hospital mainly accepted those transportation cases accelerated finding recipient hospitals for these patients. The transportation process for the patients went smoothly because, at Tohoku University Hospital, the procedures had been integrated by their HDC, not by each department as usual. Also, thanks to the efforts by Yamagata Prefectural Central Hospital, Geriatric Health Services Facilities, etc., in YAMAGATA accepted many seniors requiring nursing care. More than 500 patients for March and April in total were transported those facilities. Figure 3-7 Breakdown of transportation cases b. Support for the Transfer of Evacuees Some patients needed hospitalization, some outpatients had already completed their treatment, or those accompanying the patients, evacuees, etc. stayed inside the hospital, claiming they had no place to go home to, no means of moving (by vehicle or by bus). They numbered 600 at the peak time, lying on the floor for accommodation. In order to keep the hospital working, these people had to be moved from the hospital. The Ishinomaki RCHP asked local HDC for a shuttle bus service to the disaster shelters, which became available for two weeks from March 14. People on the list to be moved included those who had supposedly completed treatment and returner refugees staying inside the hospital. The staff tried persuading them, one by one, to move from the hospital because we are unable to even serve meals. However, few people accepted the request at first, and many of them vented their frustration because few bus services were available with limited destinations. Thus the hospital tried to locate Welfare Shelters that would accept those who needed nursing support (such as helpers) for assisted living and, after discussions with the City Hall, Yugakukan, a communication facility serving multiple purposes, accepted people from March 16. c. Whereabouts information room On March 11 an Whereabout infomation room was established in the Medical Center next to the Emergency and Critical Care Center. However, telephones and the internet were unavailable, and people flooded the Office asking whether or not their family members were receiving medical care there. In these circumstances, the room was moved the office to a tent outside the hospital on March 14, and Chapter 3 Development of Disaster Relief Activities with Ishinomaki Red Cross Hospital (RCHP) as a Hub Hospital Great East Japan Earthquake and Tsunami 107

16 Great East Japan Earthquake and Tsunami Chapter 3 added a second tent on March 16. On March 18, it was moved to a large-sized tent (air tent). Subsequently, as telephone lines and the internet were resumed, the room was closed on April 4. Initially it aimed to collect and post information on our patients. However, responding to an increase in the needs of the visitors, the service expanded and gradually shifted its focus to setting up and maintenance of the message board and collecting and providing shelter lists outside the hospital. (5) Deployment of Support Staff from the Headquarters As discussed in above, Ishinomaki RCHP had to deal with the patients and affected people flooding to the hospital from the entire Ishinomaki Medical Area under a very difficult situation in the wake of the disaster. Therefore, in addition to the medical teams, the Headquarters dispatched the support staff mainly from RCHPs across the nation based on a request from Ishinomaki RCHP. Doctors belonging to the medical teams provided in-hospital support as necessary until the end of March before a full-scale adjustment/arrangement began with a formal notice from the Headquarters. Addressed official dispatch letters to the chapters and facilities across the nation, as of March 25 were sent to the relevant pharmacists, nurses, midwives, nursing teachers, as of March 28 to internists, as of April 4 to psychiatrists, and as of April 8 to clinical engineers and administration staff. The physicians mainly provided medical services at the Regional Emergency and Critical Care Center. Due to an increase in the number of patients in the General Medicine and Respiratory Department during the Japanese long holiday season on May or summer season, human resources were arranged for each department to cope with the situation apart from the support for the Regional Emergency and Critical Care Center. The nurses and midwives supported the ward, triage, and nursing school teaching. The pharmacists mainly assisted in the preparation of medicines in the hospital. The clinical engineers provided hemocatharsis therapy and cardiovascular related services, and the administration staff were engaged in assessment duties in Ishinomaki Joint Medical Team. The support services at each department were completed, one by one, by around the end of August. However, the psychiatrists continued their services until March 31, 2012, because the need for mental care for these patients continued for a long period of time. Arrangements or adjustments to be made for staff deployment were based upon a request from Ishinomaki RCHP and the Headquarters informed the Block Representative Chapters of the requested number of dispatched staff per job title and their service duration. Under the scheme, the Block Representative Chapters requested the deployment of staff to each medical institution, mainly RCHPs, via the each chapter of each prefecture. Most of the dispatched workers were RCHP staff. The Chapters, Blood Centers, and the Headquarters also provided for cooperation in deploying administrative staff. While responding to the needs for manpower, the dispatching side gradually found it difficult to secure human resources. In addition, it was sometimes unable to provide the requested number of staff and extend their service duration. Therefore, in order to appropriately identify the local needs and smoothly coordinate staff deployment, two Headquarters staff, in principle, resided at the hospital on a rotation basis until the end of July. The staff dispatched from each medical facility across the nation gathered at the Headquarters to have a briefing, and then they entered the disaster area by using a large chartered bus. Because the Tohoku Shinkansen service was restored from the middle of May, it was possible to enter the area directly from the facilities they belonged to using the public transportation system. It was necessary to keep in mind when the staff was dispatched that they provide information to the next staff about psychosocial care for the staff, useful tips for the staff s activities, etc. The support staff took a land route to ISHINOMAKI. They arrived at the city in the evening where the sky was dusky due to the power outage and were unable to directly witness the miserable situation of the damaged coastal area. Ishinomaki RCHP did not suffer from major damage. Other than the large number of injured and sick, the situation looked as if there had been no disaster at all. And one of the major characteristics of this disaster was that even support staff member assigned to the hospital found it difficult to have a sense of reality that they were in a disaster area. Therefore, there was a huge gap between the image of medical services, their sense of exaltation and mission before their deployment, and the sense of accomplishment and fulfilment they actually obtained 108

17 from the support services; the deployed staff tended to wonder and question whether or not they really contributed to the support. Therefore, it was a point of providing a careful explanation on how the hospital and the staff was functioning. Initially they used meeting rooms in the Ishinomaki RCHP for lodging, but increasingly used accommodations in the city from around May or June. For approximately one year, more than 1,000 staff from across the nation provided support services to Ishinomaki RCHP, which was a large-scale, sustainable and unprecedented project combining the deployment of medical team staff and support to the disaster facilities. Through the coordination work by the Headquarters, 4,874 staff in total (1,477 physicians, 2,426 nurses, 839 pharmacists and 132 clinical engineers) had been dispatched for hospital support from March 12 to July 31 (or March 31, 2012 for psychiatrists) from RCHPs across the nation. 3. Joint Medical Team Activities in the Ishinomaki Area At the Ishinomaki RCHP many medical teams including JRCS medical teams gathered, where the medical functions including traveling from shelter to shelter to provide medical care were integrated as the Ishinomaki Area Joint Medical Team. As the City Hall was damaged by the disaster, the Joint Medical Team was engaged in not only medical services, but also public health and welfare activities that were otherwise provided by the local government. It is considered this is a rare example of where many medical institutions, including JRCS, cooperated with each other, serving a large-scale project over a long period of time in various areas such as medical and other services. The services provided by Ishinomaki Area Joint Medical Team are described as follows; (1) Assessment and Improvement in the State of the Disaster Shelters a. Background to the Assessment Services The HDC staff of the hospital waited until the water receded from the road, and visited Ishinomaki City Hall to assess the damage and obtained a list of 328 disaster shelters. It was estimated that approximately 42,000 people had evacuated. However, the list only covered the names of the shelters and number of people accommodated; no details were available about the needs of each shelter. Therefore, the assessment to identify the number of injured and sick was needed in order to determine which disaster shelters should be prioritized. The assessment was expected it would take a lot of manpower and so that fewer personnel would be left for traveling from shelter to shelter to provide medical care. After a discussion on whether or not the assessment is needed, finally we came to a conclusion and decided to go ahead with it because we should clearly identify the status, identifying shelters with emergency needs, and go to these first. For three days from March 17 to 19, while the medical teams traveled from shelter to shelter to provide medical care, the staff members evaluated the level of medical needs, etc. As a result of the calculation using the assessment sheets during the night of March 19, although more than one week had passed since the disaster took place, people at 35 shelters were living with a shortage of supplies of food. About 100 shelters had sanitation problems with their toilets not flushing properly. Subsequently, data of these disaster shelters was to be updated every day, posted and stored in chronological order. The data helped to determine the deployment strategies for the medical teams and to take the following measures for the deteriorating hygiene conditions within the shelters. b. Assessment Method The assessment covered the following items: the number of people accommodated in the entire shelter, the number of patients in total receiving medical services and the number according to the disease (fever: 38 C or more, coughing, vomiting, diarrhea, influenza, respiratory illness, breathing difficulty), evaluation of lifelines and the hygiene environment (water, food, electricity, blankets, heating, hygiene status/toilets), and the needs from each department (pediatric needs, psychiatry needs, obstetrics and gynecological needs, and dentistry needs). Among the above items, the lifelines/hygiene status related items and the needs per department were evaluated at four levels,,,, (Very Good, Good, Fair and Poor). There is a rough indication in the explanatory notes: (Very Good) refers to all, (Good) to 50% or more, (Fair) refers to less than 50%, and (Poor) to zero. However, the staff did not necessarily have to evaluate the items based on strict standards. What was more important to locate the shelters evaluated as (poor), and it was considered Chapter 3 Development of Disaster Relief Activities with Ishinomaki Red Cross Hospital (RCHP) as a Hub Hospital Great East Japan Earthquake and Tsunami 109

18 Great East Japan Earthquake and Tsunami Chapter 3 that there would be no significant difference among those judged as (Poor). It was also necessary to avoid causing additional stress on the evaluators with excessively detailed standards. The results of the assessment sheets were input as electronic data every day. The input work was initially provided by a Kokushikan University team and, later, it was handed over to JRCS Headquarters and Ishinomaki RCHP HDC support staff. The data was also published on the Internet with the support of Google Japan. Figure 3-8 Assessment sheet format Format omitted The data results helped to examine chronological changes in each disaster shelter. It was examined the number of people accommodated by the shelter, the number of patients receiving medical services, the changes in the ratio of patients receiving medical services (the number of patients receiving the services out of the number of people accommodated by the shelter) or the number of patients by symptom, such as coughing, etc. Discussions were held to determine the factors, if any, that caused a surge of patients at the shelter in order to increase the visits. c. Response after the Assessment Dr. Tadashi Ishii, the Coordinator controlling the Ishinomaki Area Joint Medical Team (discussed below) went to Ishinomaki City Hall for the purpose of coping with the shortage of food supplies at the disaster shelters. He also participated in a Medical Coordination Council held at the Miyagi Prefectural Office to ask for food supplies for the disaster shelters. The medical teams also arranged the delivery of food supplies to the shelter. In regards to improvements in the hygiene environment, it was difficult for the traveling medical teams from shelter to shelter to even prevent infectious diseases. Public sanitation services should essentially be the responsibility of local government officials, including public health nurses. However, both the City Hall and Health Center were affected and not functioning properly. Therefore, an Infection Control Team (ICT) from the Ishinomaki RCHP was deployed. This team carried out staff education to prevent infectious diseases from spreading within the hospital and maintained a normal hospital environment. Initially, one doctor and one nurse specialized in infectious diseases (and later, two nurses) traveled from shelter to shelter to prevent infectious diseases. First of all, ICT carried out risk assessment of the disaster shelters. They asked the medical teams traveling from shelter to shelter to roughly investigate whether or not water was available, sewage in the toilets was properly disposed of, the number of portable toilets was sufficient, etc. And based on the results, they identified which disaster shelter was facing a serious condition, and provided the necessary supplies (masks and hand disinfectants) to prevent infectious diseases with instruction on how to use them. The supplies distributed to the shelters also included masks, disinfectants, hand disinfectants, etc. As followed identifying the infectious diseases on site, lifeline availability and the number of evacuees, it was decided what should be allocated where. The team gathered these supplies by supporting from the Headquarters and personal connections. From morning to the evening, asking it was investigated how the toilets were used and cleaned as part of instruction on hygiene management with visiting up to 4 to 5 disaster shelter a day. As there was no sewage, four lots of wrap-type toilets 4 were found from the warehouse of the Ishinomaki Government Office and distributed 90 units to the disaster shelters. it was informed that alcohol disinfectant could not kill norovirus; the effective way would be hand-washing with water. In order to prepare tap water for hand-washing, tanks for smallscale water systems that are used in developing countries were provided at 11 disaster shelters through cooperation with the International Red Cross and Red Crescent. From the examination of the assessment data on the shelters that was updated every day, a follow-up the survey was conducted about coughing, fever, digestive cases, and intervened with the patients as necessary. For example, when one of the shelters had 20 diarrhea cases, ICT immediately went over there to deliver soap and focused on hand-washing instructions. (4) A portable, deodorized legless chair type toilet. One can urinate or defecate on a vinyl mat prepared in advance, then push the button to have it disposed in the sewage and have the next vinyl mat charged automatically. 110

19 d. Installation of a Short-Stay Base Patients with infectious diseases become more prevalent in the chronic phase. When it became warmer, there were more cases of chicken pox, mumps, streptococcus hemolyticus infection and handfoot-and-mouth diseases. In normal times, most of the patients would have recovered by taking a rest at home. However, there is a risk of them spreading the infection in the setting of a disaster shelter. To provide a facility for patients to stay until their recovery and in order to prevent contagious diseases (such as influenza) from spreading, a short-stay base was installed with about 20 beds on the fourth floor of Ishinomaki Royal Hospital. This was established as a high quality disaster shelter, not as a hospital, based on the following concepts. Preparing for accepting patients whose condition may worsen in the setting of a disaster shelter although they would otherwise be allowed to go home in normal times Isolating people from the shelters where infectious diseases could spread When things settled down, patients awaiting to be transported to other hospitals may be accepted (2) Assessment for Patients Requiring Nursing Care The environment of disaster shelters gradually improved, and no serious events (such as outbreaks of infectious diseases) occurred. However, the number of emergency patients did not decrease even in the chronic stage, and patients visiting the hospital numbered some 100 a day, almost double the 60 patients on average at normal times. Figure 3-9 Trends in the Number of Emergency Patients Patients rat (80 days) ta 17,344 people he e area 2,290 peopl he er e er e pat e t re a e the a e Total number The Red area a a ter the a ter and aspiration pneumonia patients due to their prolonged stay at the shelters. In particular, it was the big issue that elderly people who had been able to walk before the disaster lost their capability to walk, and those who had been independent in going to the toilet became all-day diaper users. Therefore a project was established with the city officials to focus on a welfare-shelter in order to maintain the degree of independence that the elderly people had because it was more efficient to concentrate the public health nurses and care managers who traveled from shelter to shelter at a single site. The assesment was conveyed about patients requiring nursing care at 132 disaster shelters in the former Ishinomaki area (except HIGASHI MATSUSHIMA and ONAGAWA) in a week, identifying 76 relevant patients. Out of these patients, almost half needed nursing care, and one quarter of them could move to welfare-shelters, etc. Through cooperation with the city government officials, Yugakukan was also used as a welfare shelter. This facility accommodated 358 people in total, including elderly people, infants/pregnant women, and their family members. In addition, ICT recommended that the City Hall specify the Monou Farmers Training Center as a welfare evacuation center, which was so designated on April 29. In ISHINOMAKI ICT established welfare evacuation centers at 12 sites in total one by one from the disaster day. The above centers included 10 facilities for elderly people, none of which had been designated as such before the disaster. However, the number of users of the welfare evacuation centers and welfare shelters was limited because many gave the reasons I would like to stay as close as possible to my home, I don t want to live where public transportation is limited, I do not want to be apart from my family, etc. Chapter 3 Development of Disaster Relief Activities with Ishinomaki Red Cross Hospital (RCHP) as a Hub Hospital At this stage, the increasing visitors included vulnerable groups (children and elderly people) claiming ill health, pneumonia patients supposedly caused by dust, [Welfare Shelter Established for People Requiring Nursing Support (Yugakukan)] Great East Japan Earthquake and Tsunami 111

20 Great East Japan Earthquake and Tsunami Chapter 3 Welfare Evacuation Centers These are institutions designated under the Disaster Relief Act. According to the Guidelines on the Establishment/Administration of Welfare Evacuation Centers prepared by JRCS, people eligible to attend such a center include those who have special needs regarding their living shelter (such as elderly people, challenged people, pregnant women, infants and sick people), and those who do not need to be hospitalized at care insurance facilities or medical institutions but require home nursing care. The prefectures, cities, towns and villages shall establish these centers at designated disaster shelters (elementary and junior high schools, public halls, etc.), welfare facilities for the aged (day service centers, etc.), welfare facilities for the disabled (both public and private), health centers, schools for disabled children, lodging accommodations (both public and private) and provide the following services. One life consultant staff for every 10 evacuees was assigned Consumption items including paper diapers, stomas were secured in addition to portable toilets, handrails, temporary slopes, information transmission systems, and partitions (3) Providing Medical Services for Diseases Caused by Conditions in the Disaster Shelter The newly established welfare evacuation centers, etc., allowed for a decrease in the number patients requiring nursing care to some extent. However, if the same conditions remain, it is considered that it will have some impact on their health, including muscle weakness. Those staying in the shelters for a prolonged period had a higher risk of developing or worsening diseases due to the aggravation of the living environment, climatic and psychological factors. a. Locomotive Syndrome, Aspiration Pneumonia, etc., in Elderly People People in a disaster shelter have decreased mobility, sitting or lying down even in the day. In particular, elderly people are unwilling to move because of the difficulty of getting up from the floor, which results in a loss in muscle strength. An investigation of independence ability targeting about 1,000 elderly people staying at the shelters over the one month after the disaster was conveyed with the cooperation of Miyagi Physical Therapy Association/Association of Occupational Therapists. According to the results, people who were bedridden or close to bedridden status almost doubled in number compared to before the disaster. Those who needed assistance reached 2.3% of the total. Aspiration pneumonia cases due to being bedridden increased (one of the causes was insufficient oral care because people were unable to brush their teeth due to water shortages in the areas where water services had not been restored), and the number of people that had to be transported to the hospital increased. Coughing, sputum, breathlessness and dyspnea cases increased as well. b. Improvement of the Deep Vein Thrombosis (DVT) Positive Rate Immediately after the disaster, the shelters became densely crowded. This increased the positive rate of DVT; however, it decreased gradually. On April 21 the schools resumed activities and those sheltered in schools had to move to gymnasiums and local community centers. The evacuees cleaned their houses in the day time and returned to their accommodation at night. Thus, some of the shelters were again densely crowded. The shelter space per person was about a single bed or smaller in which they were unable to move or sleep well. This may have affected the increasing positive rate of DVT, along with a higher risk of cerebral infarction. c. Information on Economy-Class Syndrome (ECS) to Raise Awareness Ishinomaki RCHP asked the medical teams visiting the disaster shelters on March to remind people about the ECS. The instructions included taking enough water, eating and exercising, etc. However, due to the poor conditions in the shelters, such health tips were far from accepted. From March 23 compression stockings (500 pieces each of S, M, L and LL sizes) were distributed to prevent ECS at the shelters. Also, as for the prevention of ECS, test apparatuses were collected and using lower limb venous ultrasonography was started from March 27 at the shelters. This examination revealed that there were many patients suffering from ECS. The Ishinomaki RCHP staff visited disaster shelters with physical therapists to recommend that the evacuees be physically active and conducted exercises with them. d. Influence on Chronic Diseases The stress of life in a shelter can change the conditions of patients with chronic diseases, causing high blood pressure, myocardial infarction, etc. Some of them who were taking Warfarin were transported due to cerebral hemorrhaging although 112

21 they had taken the same dose of this anticoagulant drug (that can help prevent blood coagulation) before the disaster, and even lethal cases were observed. As the result of the test of the anticoagulant effects of Warfarin in the patients taking the medication, it was found that some of them indicated obviously higher values. It is considered that the unbalanced diet at the shelter had affected their health. Thus, the medical teams decided to provide the above test once a month when adding the prescription of Warfarin at the shelters. Some of the patients taking Warfarin even self-adjusted the dose when the drug was scarce. In this case, too, their test results were considered and re-established the doses. Some people were unable to report that they were taking Warfarin. Therefore, the RCHP staff asked the patients in the inquiry, did your doctor tell you not to eat natto (fermented soy beans)? 5 in order to acquire information on their medication history management. An unbalanced diet may also affect the blood sugar control of diabetes mellitus patients, and the medical teams had to provide a service for blood sugar control. (4) Services by the Ishinomaki Area Joint Medical Team On March 20, MIYAGI and ISHINOMAKI local government officials gave Dr. Ishii a free hand in establishing the Ishinomaki Area Joint Medical Team, a team organized by staff across the nation with an integrated chain of command. [Staff meeting of the Joint Medical Team] a. Administration of the Teams Based on the philosophy of offering hygiene, health care and mental stability through medical services to all people living in the Ishinomaki Area, the Ishinomaki Area Joint Medical Team provided medical services and surveillance on medical needs in the Ishinomaki Area, and medical support to Ishinomaki RCHP, a hub hospital for disaster response. The participating medical teams are listed below. Japan Medical Association and Japan Dental Association Medical Care Teams Tohoku University Medical Team, Ishinomaki Municipal Hospital (local) University Medical Teams dispatched under contract with Tohoku University Hospital Medical Teams dispatched under contract between the prefectures JRCS medical teams Psychiatrist Groups SDF Medical Teams Doctors familiar with disaster medicine joined forces on a rotation basis immediately after the disaster in order to support Dr. Ishii, a commander of the Joint Medical Team, coordinating the orientation for the medical teams, assigning service areas and providing advice and guidance on the decisions on service strategies. More personnel were needed to handle a great deal of administration work and maintain the functions of the headquarters, thus nine staff, in addition to two assistants of Dr. Ishii, were in charge of administration services for the newly established department. Registration/erase of the medical teams (maintenance, management, listing of them) Management/maintenance of assessment data updated daily Data control, including daily reports on the condition of each patient and the number of visiting patients Control and delivery of supplied materials Maintenance and store of the Daily Records of the medical teams Preparation and control of a Line Table Acquisition, organization and delivery of various documented information (traffic conditions, gas station locations, etc.) Daily update of documented meeting references and minutes A great deal of coordination with the organizations deploying the medical teams Preparation of a chronology (recording of a timeline or sequence of events) Maintenance of supplies lent to the teams However, due to the heavy workload, nine staff on a 24- hour basis was not enough to deal with the data, including data management. Chapter 3 Development of Disaster Relief Activities with Ishinomaki Red Cross Hospital (RCHP) as a Hub Hospital (5) Because natto containing high Vitamin K counteracts the effects of Warfarin. Great East Japan Earthquake and Tsunami 113

22 Great East Japan Earthquake and Tsunami Chapter 3 In these circumstances, JRCS continuously deployed 1,501 support staff in total to the headquarters from March 12 to July 31 (including 206 doctors and 1,295 nurses / administration staff / volunteers). They were in charge of collecting information on the support teams, carrying out assessments and registering the Daily Records of the medical teams. Four nurse managers from the Sendai RCHP were also engaged in recording a range of negotiations and the preparation of team lists on a rotation basis. Furthermore, staff from the Headquarters and Chapters resided for liaison and coordination. This support enabled the administrative staff in the hospital to focus on secretarial duties (accompanying meetings, preparation of minute summaries, preparation/management of documents for media interviews, preparation of the chronology, scheduling, etc.) This enabled the staff to handle a great deal of information on time, providing such information to doctor leaders immediately. The leaders assessed the current situation to decide on their service strategy. Under the Area / Line System, considering the number of disaster shelters, etc., the areas around ISHINOMAKI were devided into 14 zones, and appointed medical teams available for long-term service as Area Leaders, leaving the management of the areas in their hands. The medical teams were divided into a Line, medical teams that provided support for one month or longer, and a Spot, support teams active for a short duration of time. Figure 3-10 Organization of the Area / Line System Figure omitted The necessary number of Line teams under an Area Leader was allocated, adjusting it for each area depending on whether or not a clinic was resumed or disaster shelters were consolidated/abolished. This aimed at providing long-term, stable medical support by subdividing, consolidating and abolishing the areas themselves. The number of medical teams to be deployed was decided based on the results of the assessments made at the shelters. [Staff supporting the Joint Medical Team] b. Introducing Area / Line System Almost two weeks had passed since the disaster. However, staff at the Ishinomaki RCHP were extremely exhausted, what with inquiries about the medical teams and supplies night and day, the staff registry ceremony from arrival to leaving. Because of the high turnout of medical teams, the assignment work became more complex, and until midnight every day the staff had to decide on the service site assigned to each team for the following day. Also, a problem that was very time wasting was that many medical institutions managed their services at their own discretion. In this context, it was decided to introduce a system that was to be called Area / Line System later, in which a team serving for a long period of time should be responsible for its own management to some extent. c. Toward Reviving Community Heath Care The services provided by the medical teams gradually improved the environment of disaster shelters, avoiding serious consequences such as the spread of contagious diseases. As the number of shelters was decreasing and the local medical institutions resumed their functions, the services provided by the medical teams gradually declined. However, the number of emergency patients transferred to Ishinomaki RCHP did not return to the level of before the disaster due to the significant impact of the Ishinomaki Nighttime Emergency Center and Ishinomaki Municipal Hospital, which had been heavily damaged and had no prospect of resuming services. Support was also sought for OGATSUMACHI and KITAKAMICHO, which were severely damaged by the tsunami. The medical teams had been dispatched to the Ishinomaki Medical Area until September 30. One problem in particular was that KITAKAMI and OGATSU/OSU became areas without a doctor. Another problem was the collapse of the Kitakami Bridge, which caused ambulance vehicles to take time to get access. To cope with this problem, first-aid stations were established in the areas without a doctor (including Hashiura First Aid Station in a flooded area where 114

23 one team was dispatched per day, while practicing evacuation drills). The Ishinomaki RCHP negotiated an increase in the shuttle bus services and appealed to the related agencies to secure transportation means for the elderly people who had lost their vehicles or their family members who could drive them by car. The First-Aid Stations continued to be run until September 30. In this chronic phase, the focus was on how to connect to and revitalize local medical services, and how to make a soft-landing to restore them to their previous state. To this end, the goal of our services was to achieve independence support whereby people could find and visit their own primary care physician and not be too dependent on the medical teams. And the following strategies for our services were established until the withdrawal. To inform people that the teams would be active for a limited time (so that people did not take it for granted that the medical teams will be always available) To provide information on practitioners that had resumed their services and recommend people to visit them To reduce the frequency of visits to the shelters; i.e., from every day to once a week. To have people secure their transportation means (such as a shuttle bus service) in rural medically underserved areas and to get medical services for themselves. Four fixed-point medical stations were established with free shuttle bus services for a limited time that traveled between the City Hall, private clinics, JRCS, shopping centers and the shelters. To take continuing measures to provide for patients in need of nursing care since the shelter accommodating these patients will not be closed. To provide health and safety management for disaster victims To keep providing services at fixed medical stations in rural medically underserved areas, the goal of which was to establish clinics. Finally, to ensure that the clinics provide medical services under the health insurance. As mentioned above, the Joint Medical Team was designed only to play the role of revitalizing the collapsed local medical services. Figure 3-11 Changes in the number of Ishinomaki Area Joint Medical Teams Note) Teams serving for more than one day were counted as one per day. Therefore, the number of medical teams is not the same as those in Chapter Approach from Before the Disaster As discussed in the above, Ishinomaki RCHP was able to maintain its functions at the time of the disaster, providing medical services on an extensive scale. This is because the hospital had been engaged in a range of activities toward creating a disaster-proof hospital even in normal times. (1) Preparation of the hardware parts of Supporting Hospital Functions a. Location The Ishinomaki RCHP, which was relocated from Minato District (to the east of Kitakami River) in the coastal area to Abuta District (about 4.5 km directly from the sea) in an inland area in 2006, avoided any impact from the tsunami this time. Situated at the site where the former Ishinomaki RCHP used to be five years ago, the flood water reached the ceiling of the first floor of the Ishinomaki Red Cross Nursing School building. b. Quake-Absorbing Structure As the hospital adopted a quake-proof structure absorbing the level of energy released by an earthquake due to its base-isolated layer, there was no significant damage to the building and medical equipment. The quake-absorbing structure protected the information system as well, allowing electric charts and ordering systems to be used just by inputting patient data on the PC. For diagnosis and testing services, it was important to be able to obtain patient information just by viewing the monitor. If the system had been down, the hospital would have had to use paper slips that we had not used on a daily basis amid the turmoil with the Chapter 3 Development of Disaster Relief Activities with Ishinomaki Red Cross Hospital (RCHP) as a Hub Hospital Great East Japan Earthquake and Tsunami 115

24 Great East Japan Earthquake and Tsunami Chapter 3 flood of patients after the disaster. Not only would this have caused chaos, it was expected that it would have increased the burden of manually inputting the medical data. could be liquefiable in the wake of a major earthquake. As a result, the tsunami water flooded the rice fields around the site through agricultural waterways and other routes. In the morning of March 12 the water fulfilled the rice fields; however, the site was saved from flooding. [126 units of quake-proof equipment supporting 35,000t building] Figure 3-12 Outline of the Ishinomaki RCHP building Structure 7th floor 1st basement 1st floor of the tower Rabar Structure (Specialized Structure), Quake-Absorbing Structure Completion year May 15, 2006 Site area 69, m 2 Building area 101, m 2 (including the main hospital ward/accessory ward) 32, m 2 (including the main hospital ward/accessory ward) Total floor space 32, m 2 Quake-proof equipment Laminated rubber: 6 units, steel L-type damper devices: 16 units Seismic isolation rubber integrated U-type damper devices: 30 units Elastic sliding bearings: 74 units c. Banking for the Foundations and Sand-Piles As the hospital is situated in the watershed areas of the former Kitakami River basin, we designed the landscape expecting flooding, raising the ground level higher than the flood level in the past. There is a diluvial formation 60 meters underground, thus friction piles were used for the foundation structure. This includes a mixture of clay layers in the middle which may sink or subside under strong pressure, and sand layers through which strong acid groundwater flows. A Piled Raft method was adopted to help relieve the burden on the piles. Also, sand-piles were used because the sand in the superficial layer (up to 10 meters under the surface) d. Turnaround Drive and Large Eaves The space before the front entrance prepared as a turnaround drive was not used other than for events. However, it was effectively used for parking the vehicles of the JRCS medical teams, setting up tents for living and for information on the whereabouts of the affected people. The large eaves (roof set before the front entrance for the turnaround drive) were about an area of 25 m 15 m and 5m in height without an uneven surface between the road and the building. In the event of a disaster this allowed for flexible use of services, such as triage, the setting up of a tent for medical practice, etc. e. Heliport Located at Ground Level Considering the convenience for the SDF and Fire Fighters, one unit of a heliport located at the ground level was established, the cost of which was lower compared to that of a heliport located on the roof top. The ground was also improved so that an air ambulance could move horizontally along the route connecting the heliport and the emergency entrance, allowing for the more efficient transportation of patients. This was very effective at the time of the disaster when many injured people had to be transported. Since the elevators had stopped, it was hard work to move the patients manually from the rooftop heliport to the Red area on the 1st Floor. Emergency entrance Heliport [Bird s eye view (aerial photograph) of the hospital building and heliport] 116

25 In order to identify the achievements of the seminar, in January 2008 a tabletop exercise was provided that assumes how the hospital should respond to a largef. Underground Service Yard Cots, mattresses, etc., were stored in a storage warehouse in the parking lot. However, the stockpile was not enough to meet the demand. The underground service yard (which had been always used for the transportation of supplies from chapters and facilities around nation) had a wide space for transportation and storage, allowing smooth and efficient transportation using trucks. g. Outdoor Electrical Outlets and Medical Gases in the Waiting Hall It was useful to have installed "outdoor electrical outlets for external generators at the pillar of the front entrance. The number of patients increased on the third day after the disaster, on March 13. The patients who could walk in the Green area were moved to the deru of the JRCS Medical Center set up outside for medical services. At this time, the electrical outlets installed outdoors were very useful. On the wall of the east side of the Waiting Hall, which had been used for treating patients triaged to the Yellow area, we installed and effectively used corridor wall-mounted medical gases (four oxygen outlets) which had not been used at normal times, as well as medical outlets for patients using oxygen inhalers. [Medical gases and electric outlets installed in the corridor of the Waiting Room] (2) Inprovement of the Disaster Regime and Human Development Having not experienced a massive earthquake since 1978, Miyagi prefecture estimated that major earthquakes would occur at a likelihood of 70% in 10 years, 90% in 20 years, and 99% in 30 years After the relocation, Ishinomaki RCHP focused on disaster countermeasures, including working on a full-scale revision of the Disaster Response Manual) in a. Preparation of the Disaster Response Manual Due to changes in the building and facilities of the hospital, which was relocated and newly constructed in May 2006, the Ishinomaki RCHP decided to work on a full-scale revision of the Disaster Response Manual prepared in In February 2007, a Subcommittee on the Disaster Response Manual was organized as a sub-organization of the the Disaster Preparedness Committee (chaired by the Hospital Director). With reference to the disaster manual by the Disaster Medical Centers of TACHIKAWA, TOKYO, a team consisting of three doctors, six nurses, and two paramedics (pharmacists, radiography and laboratory technicians, etc.) gathered every other week for one year, sharing their responsibilities according to their job titles to produce the manual. In preparing the manual, the names of the managers of each department (updated upon every transfer) were included, because not only what to do but also who to do it was considered important. The hospital also interviewed the staff to find out their views and reduced the amount of text so that it was more readable. b. Seminars and Training Participants in the seminars were mainly members of the six medical teams with a high level of awareness of disaster medical services, but it had to be expanded to involve more staff. To this end, a seminar on disaster management for all of the staff was started in A Program for Basic Seminar was developed to allow the participants to study from the basics, and those who took the seminar once may then become an instructor of the Basic Course, to pass on the knowledge to the staff within the hospital. As a result, the number of participants in the seminar increased to 723 in FY2007 from only 73 in FY2001. The RCHP developed an annual plan for the Medical Seminar Program, which was about an hour session that started at 17:30 every Wednesday. Figure 3-13 Attendance at the seminar on disaster Management FY2001 FY2006 FY2007 FY2008 FY2009 FY participants participants participants participants 611 participants 523 participants Chapter 3 Development of Disaster Relief Activities with Ishinomaki Red Cross Hospital (RCHP) as a Hub Hospital Great East Japan Earthquake and Tsunami 117