PROBLEMS OF EMERGENCY MEDICAL CARE AT THE TIME OF THE GREAT HANSHIN-AWAJI EARTHQUAKE

Ukai T.

Osaka City General Hospital, Osaka, Japan

SUMMARY. The distinguishing characteristic of the Great Hanshin-Awaji earthquake which hit Kobe and its vicinity in the early morning of 17 January 1995 was that the tremor directly affected a highly urbanized city and revealed the fragility of human life in a sophisticated modem metropolis. The scope of the damage included damage to medical facilities. The difficulties encountered in the early relief activities are also reported.

Introduction

Some parts of the world are particularly prone to earthquakes (Fig. 1). As Japan is located on the Pacific seismic and volcanic rim, it has been hit by a number of earthquakes in the past. Japan lies over four tectonic plates: the North American Plate, the Pacific Plate, the Philippine Sea Plate, and the Eurasian Plate (Fig. 2). The Pacific Plate and the:Philippine Sea Plate are moving slowly beneath the other two, and when the distortion between the plates reaches a certain extent parts of the plates break and release accumulated energy, causing earthquakes. This is the tectonic type of earthquake. Most earthquakes occurring in and around Japan are of this type. Some violent tremors were not however tectonic but of the direct hit type, caused by the movement of active faults not along the border of tectonic plates. The Great Hanshin-Awaji Earthquake which hit Kobe and its vicinity with a magnitude of 7.2 on the Richter scale at 5.46 am on 17 January 1995 was a direct hit earthquake. As this area had not been struck by a big earthquake for about 400 years, the local residents were not prepared for such a tremor, in spite of warnings given~by seismologists several years ago. Medical facility managers and hospital administrators were also unprepared.

The epicentre of the earthquake was about 14 km under the northern tip of Awaji Island, which is only about 20 km from downtown Kobe.' The earthquake that hit Kobe, one of the world's largest port cities, was of the shallow and direct hit type. The most severely damaged area was the central and eastern part of Kobe (Ashiya and Nishinomiya) (Fig. 3).This area is highly developed and with Osaka forms the second largest metropolitan area in Japan. It is a very popular residential area with a mild climate, beautiful scenery, and good transport connections.
The main traffic arteries, national routes 2 and 43, highways, and several railways joining the eastern and western parts of Japan run through the area.

Fig. I - World distribution of earthquakes of more than magnitude 4.0. About one-tenth of these earthquakes occurred in and around Japan. Fig. 2 - The four tectonic plates on which Japan is located. Fig. 3 - Epicentre of the Great Hanshin-Awaji Earthquake and the area most affected. Fig. 4 - Collapsed old wooden house. Rescue squads of police and selfdefence forces searching for buried persons.

The violent tremor lasted 20 seconds or less, but 101,233 houses were completely destroyed and about the same number semi-destroyed. The old wooden houses with heavy tiled roofs collapsed, blocking the streets and obstructing rescue and relief activities (Fig. 4). Reinforced concrete buildings built according to the old construction code were also damaged (Fig. 5), but those built according to the revised construction standards of 1981 did not suffer serious damage.
An extensive and uncontrollable fire broke out after the earthquake in the Nagata ward of Kobe, which has the highest population density in the city. In this area there are many old wooden houses and apartments as well as numerous small factories manufacturing rubber shoes. Water was not available from fire hydrants as the supply had been suspended, and fire-fighting was consequently extremely difficult. It took more than 30 hours to extinguish the fire, using sea-water. Overall, the fire after the earthquake burned out 7,456 houses in over 530 localities.
Streets, bridges and railways were also seriously damaged. Damage to elevated highways was particularly serious, which not only prevented traffic on the highways themselves but also on the streets beneath them. Some newly constructed elevated highways were also inactivated, especially those built on reclaimed artificial land which was flooded. (Fig. 6). Three hundred and eighteen bridges collapsed and roads were severely damaged in 9,408 place&..
Railways were damaged in more than 90 places.' Millions of people were thus deprived of their means of mass transportation (Fig. 7). The elevated Shinkansen (bullet train) railway, which runs at a speed of up to 250300 km/hr, was also damaged. If the earthquake had occurred one hour later, several trains would have been derailed and crashed off the elevated railways, causing thousands more dead and injured.

Fig. 5 - Severely damaged building in Kobe. Fig. 6 - Elevated highway collapsed on reclaimed land. Fig. 7 - Derailed Kankyu line train. Fig. 8 - Number of patients presenting at hospitals in Nishinomiya on 17 January 1995 (in parentheses the number of dead bodies brought in).

The tap water supply was cut off in 1,260,000 households, the city gas service in 845,000 households, and electricity in one million households. As for the telephone service, 285,000 lines were disrupted; the number of calls to the affected area increased to 50 times the usual level, causingan overload on the switchboard circuit. Telephone calls to the disaster area were thus almost impossible on the first, the second and even the third day following the disaster. The final death toll was 6,308, including secondary deaths in some way related to the tremor. About 35,000 persons were injured. 316,678 inhabitants were evacuated to 1,153 temporary shelters. According to the report of Dr A. Nishimura of Kobe University, Department of Forensic Medicine, the most frequent cause of death was traumatic asphyxia (53.9%), followed by crush injury in the chest or the whole body (12.5%). The third most frequent cause of death was burns and CO poisoning (12.2%).' In some cases, when the bodies were charred, it was impossible to judge whether the victims had died before the fire or had been burned to death.

As so many houses were destroyed and persons trapped all at the same time, with numerous fires breaking out, the emergency calls to the local fire departments overwhelmed their capacity. In spite of the maximum efforts of rescue personnel, paramedics and ambulance crews, it was impossible to respond to every call. In some places people had to dig out buried family members or friends almost with their bare hands. On-site triage of the casualties by professional rescue and ambulance workers was almost impossible.
Many mildly and severely injured patients and even dead bodies were rushed by family members or neighbours to hospitals in the disaster area, which were themselves variously damaged and in a state of general confusion. It was also cold and dark in the hospitals, which had no electricity, gas or water supply. There was also a shortage of medical resources (sterile material) and human resources (physicians, nurses, clerical personnel) in the hospitals, especially in the first six hours after the disaster.

Damage to medical facilities was a serious problem. Out of the 180 hospitals in the disaster area, four were completely destroyed and 110 suffered serious structural damage. The 1,809 clinics in the area were similarly affected. Most of the sophisticated medical equipment, such as magnetic resonance imaging apparatuses, computed tomography, X-ray angiography apparatuses and chemical autoanalysers, was damaged and unserviceable.
In Kobe City Central Hospital, which is the core hospital in Kobe, water tanks on the roof were damaged and water poured down into the wards. As the water level in the tanks dropped, water was automatically pumped up from other water tanks in the basement and eventually all the stored water was lost. The lack of water resulted in the breakdown of the water-cooled home power plant. The hospital electricity supply thus stopped completely about 30 min after the earthquake. Whatever medical instruments had escaped direct damage could not be operated anyway.
Apart from structural damage and damage to hospital equipment, the reduced presence of hospital personnel also decreased hospital functionality. The attendance rate of personnel in hospitals on the first day of disaster was 58.4% for physicians, 35.0% for dentists, 44.2% for nurses, and 3 1.0% for clerical staff. In the first hours, when the hospitals in the disaster area were extremely busy, less than 50% of personnel were able to attend their hospitals.

As said, telephone lines were damaged or overloaded, with the result that this form of communication between hospitals was difficult in the first two or three days. The hospitals were not equipped with any form of radio communication system. On the first day, most of the medical personnel in the disaster area did not know that the hospitals in Osaka, only 20-25 km from the disaster area, had suffered no damage. TV news programmes showed scenes of fires and destroyed highways, but did not give any information about the chaos in the hospitals or about undamaged hospitals.

The widespread destruction of streets, highways, bridges and railways caused severe traffic problems. Within an hour of the tremor every practicable road in the disaster area was full of cars with people leaving the area or on their way to visit family members to ascertain their safety -some even on their way to work. It was not uncommon to take several hours to drive 10 km. These conditions delayed the mobilization of relief teams from neighbouring areas and complicated the transportation of casualties.

Although the hospitals in the central disaster area were extremely crowded, very few casualties were taken to hospitals outside the disaster area which had suffered no damage. For example, small to medium-sized private hospitals in Nishinomiya (south, west and north), which have 150 to 190 beds, were overwhelmed with more than 1,000 patients each on the first day. On the contrary, only about 60 patients presented at the Hyogo Medical College Hospital, which has about 1,000 beds and is located not many kilometres from the severely damaged area (Fig. 8). With the interruption of telecommunication systems and the serious traffic jams, a journey even of only a few kilometres was regarded as an infinite distance by the general public and ambulance crews.

Because of the traffic congestion and the lack of appropriate information exchange between medical facilities, the transport of severely injured patients from damaged hospitals to unaffected hospitals was somewhat delayed. When the severity of the damage in Kobe was reported on TV news programmes, most of the tertiary emergency centres in Osaka prepared beds to receive large numbers of casualties. But in the first twelve hours only three patients were transferred to these emergency centres.

The characteristic pathologies of the patients injured or killed in the earthquake were:

• traumatic asphyxia and direct whole body crush injury, which were the most frequent causes of death

• fracture of the spine and spinal cord injury, which required hospitalization, although the fate of the paralysed limb was normally already determined, regardless of emergency surgery

• crush syndrome, which needed careful attention on the part of the physicians in the early phase

In the first two or three days some crush syndrome patients died or developed shock, serious arrhythmia, acute renal failure, and compartment syndrome. When however these patients were brought to hospital soon after extrication their vital signs tended to be stable at first, and in many cases no apparent external traumas were visible. But for the use of the Foley bladder catheter and the testing of serum potassium and creatinine kinase levels, the clinical diagnosis of crush syndrome would have been difficult for physicians without specific trauma centre training.
According to the extensive survey conducted on the 6,107 patients hospitalized after the earthquake, 372 presented crush syndrome, with a mortality rate about twice that of other trauma patients.'

At the peak point of the disaster, more than 310,000 persons were evacuated from their homes to temporary accommodation centres, such as schools, gymnasiums and other public buildings. There was no electricity, water or gas supply for several days and even weeks in these temporary shelters. Minimum supplies of food, clothes and blankets were soon provided, but sanitary conditions in such circumstances were far from perfect. The earthquake occurred in the coldest season of the year, and many persons caught cold while living in the shelters. In the early stages most clinics were closed and could not provide primary health care services for evacuees.
Countless numbers of volunteer medical relief teams fortunately came to the area from all over Japan and provided medical services for several weeks and months. Some 90% of private medical practitioners were however able to reopen their clinics within six weeks, thus restoring local medical services.
National and local government agencies began to provide temporary dwellings in March for those who had lost their homes. As it was difficult to find sufficient vacant land for all these temporary houses, they tended to be built at some considerable distance from the earthquake area. Many displaced persons thus lost touch with the original community with which they were acquainted.

The Great Flanshin-Awaji Earthquake was certainly unprecedented for Japanese people, not in its scale but because it affected the country's most highly developed modern city and revealed the vulnerability of human lives in a metropolis. The disruption for weeks and months of vital public services such as water supply, electricity, city gas, sewerage, garbage collection, telephone services and public transport made people's lives in the urban area intolerable. Disaster response plans defined at the level of national and local government did not at first function properly because the core organization (city government and prefecture government) failed to respond in the early phase. Lack of information and the breakdown of telecommunication systems led to disorganization of the disaster response. Medical services were also disrupted, The social groups most severely affected were the elderly and the handicapped - in collective areas of temporary accommodation, senior citizens over the age of 65 yr accounted for more than half the population. This social group therefore requires careful attention.
Fortunately, social life was not disturbed by any silly rumours or tumults. A promising sign for Japanese society is that a good number of young people joined in the volunteer relief activities after the disaster in many different fields. Laws and regulations related to disaster preparedness and response have been reconsidered in the whole area and some have already been amended. An educational seminar on disaster medicine sponsored by the Japanese Association for Acute Medicine was held last March and other disaster medicine seminars will be held during the current year.

RESUME. Uaspect caractéristique du grand tremblement de terre de Hanshin-Awaji qui a atteint Kobe et ses alentours tôt le matin du 17 janvier 1995 a été que le séisme a touché directement une cité fortement urbanisée et a révélé la fragilité de la vie humaine dans une sophistiquée métropole moderne. Aussi les structures médicales ont subi des dégâts écrasants. UAuteur décrit en outre les difficultés des premiers secours.

Acknowledgement. The author would like to thank Prof. S.W.A. Gunn and Prof. M. Masellis for inviting him to the 9th Meeting of the Mediterranean Club for Bums and Fire Disasters and allowing him to present a report on the Hanshin-Awaji earthquake.

BIBLIOGRAPHY

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