After the Earthquake: Updates from Japan
John Wocher, executive vice president of Kameda Medical Center in Kamogawa, Japan, shared a first-hand account of the earthquake and tsunami that struck Japan on March 11, 2011. Mr. Wocher, an honorary alumnus of the UI College of Public Health Master of Health Administration program, regularly hosts health management students from Iowa for summer internships. His updates captured a snapshot of one hospital's response during the first few days of a major national disaster.
Tuesday, March 15, 2011
Good Morning Friends and Colleagues --
Everyone knows that on Friday, March 11, Japan suffered a massive earthquake which now has been revised as a magnitude 9.0 quake. Here on Tuesday morning [March 15], the full devastation continues to be the subject of major news worldwide, and it is horrific. Regular programming is still not being broadcast widely. Yesterday close to noon, another explosion in the Fukushima nuclear plant. Today, news of a partial meltdown, but information is vague in terms of what actually happened.
At the moment of the quake, I was at my desk on the seventh floor of a 35-year-old hospital building [a view from the hospital is pictured below], which was not build to current seismic standards. As this is written, I can hear the pile drivers outside my window as the scheduled replacement building is being erected. My building is slated for demolishment, hopefully by controlled means, but on Friday, I was not sure. We are a 1,000-bed medical center, had slightly over 800 patients in the hospital, and perhaps 1,200+ outpatients in an adjacent building. At mid-afternoon, there were probably more than 2,000 visitors in the inpatient towers and a full staff of 2,000+ employees at work.
The quake started small as so many do, usually subsiding in a minute or less. This one built in intensity and lasted for three or four minutes. The building creaked and moaned, light fixtures swayed, and windows rattled. In 20 years here, having experienced many tremors, this was the first time I was scared. We are 300 km south of the epicenter, 80 km south of Tokyo directly on the Pacific coast in a town called Kamogawa. Most of the staff in my building hurriedly walked across a connecting bridge to a safer building. As soon as the swaying was over, there was a nationwide alert for tsunami along the Pacific coast of Japan, including my location.
Big tremor (magnitude 6.4 just now) and I just returned from walking across the bridge to a safer building. (This happened yesterday morning, and again yesterday afternoon.) This may happen frequently today, and we are now four days post-first quake. This morning at 6:20 there was a 4.5 magnitude quake in Ibaraki just north of us, not too far. No tsunami.
After the initial quake and tsunami warning, we began moving ambulatory patients laterally to two buildings that are at current seismic standards, moving them to floors above the second floor, but not much higher due to aftershock concern. Most were moved above the second floor due to tsunami concern. It was very orderly, no panic. It is important to pre-identify which patients are ambulatory on their own, which can be moved with assistance/wheelchair, and which patients cannot be easily moved.
My medical center is only 50 meters from the Pacific Ocean. Overhead announcements were made in all buildings asking staff to assist outpatients and visitors to locations above the second floor in our two safest building. This was orderly and not problematic. A tsunami was predicted within 30 minutes at my location, so there was ample time to clear lower floors in all buildings. The tsunami was predicted at 1 meter in my location, but was actually much lower, resembling high tide rather than a tsunami. We watched the ocean in front of us carefully, everyone quite apprehensive.
Once the danger--at least for the time being--was over, we continued to look at further contingency planning. We worked without overhead lighting in all administrative areas. Since the quake, lighting was held to an absolute minimum to conserve power. Several teams were formed as 24/7 working groups. One was to give support to staff who had relatives in the quake-affected areas. We also had medical supply inventory and placed additional orders thinking that transportation will be interrupted and not all roads/rail lines are operating even today.
All staff is asked to bring in bag lunches from home to ease the burden of food preparation staff who have patient food as a priority. We have a 24/7 convenience store in the hospital, and it was short of delivered prepackaged food this morning. Some panic buying, but not excessive and very orderly. We have contingency canned and dried food and a stable flow-through water supply, but renal dialysis patients are at great risk in the short term as well as respirator dependent patients and those who cannot be moved or cannot be easily moved. We have not had to dip into emergency rations.
In mid-afternoon, more than 40 renal patients were tethered to their dialysis machines when the quake hit. Reassuring them was a priority, and fortunately no interruption of power or water occurred. Contingency planning for renal dialysis is a key component of any disaster plan.
We cannot accept patients exposed to high radiation doses, and most will be transferred to university hospitals if this becomes widespread. We have bone marrow transplantation physicians, but are really not set up to handle these kinds of patients. We are extremely worried for pregnant women in, near, and within 100km of the Fukushima nuclear power plant. If there is a meltdown, this can have catastrophic results for those downwind and could reach far beyond the immediate area.
Our disaster plan calls for the setting up of a contingency team in our safest building, and that was staffed rapidly. We use low-power PHS phones, which only work within the building on an internal network. That was important, as cell phones were overloaded with callers calling loved ones. Internal communications have remained very stable. Even today, cell phone use is not stable.
We have a process that is fairly rapid in which each ward calls into our central contingency team to report on the status of patients, and within a hour or so we had that information, including the numbers considered ambulatory on their own or ambulatory with assistance/wheelchair.
We have had numerous aftershocks, but only a few severe here, and we are somewhat settled back to where we were on Friday, ready to implement vertical and lateral evacuation of patients again if the situation dictates. Engineering staff walked every floor in every building looking for any structural damage. We had none. We do not want to move patients outdoors where the risk is considered greater due to weather and tsunami possibility.
Most fortunately, during this time we had completely intact buildings and no interruption of electricity or water. We have co-generation so can be self-contained if we lose commercial power, but with a magnitude 9.0 quake and a 10-meter tsunami possibility, all bets are off. Had that happened here in our location, we would have lost the medical center without a doubt, with great loss of life and property.
In spite of the incredibly horrific damage and loss of life elsewhere, several things could have been worse, believe it or not. The quake occurred during the day when announcements to move to higher ground could be heard and many television sets were on with the word travelling fast. There was some time between the quake and prediction of tsunami--never enough, but we had perhaps 30 minutes with areas affected having less. Many persons made it to safe locations. No panic, very orderly, and it is amazing how many persons made it to high ground under the circumstances. Reporting in Japan is lightning fast and accurate.
A night quake with tsunami is very, very bad. People are asleep and TVs are off, but electricity was disrupted in many areas due to the quake, so TV news would not have helped. Sirens went off in affected areas and were heeded. City halls were manned, and at full strength to quickly coordinate evacuation. Weather is cold in the affected areas, but it was not the dead of winter, although many areas still had snow. Several areas had freezing temperatures last night, but late January weather would have posed more significant exposure risks, particularly for the elderly.
What was bad was that high ground in many affected areas was quite far away. Children were in school--that is a major dilemma in getting groups evacuated to high ground quickly, particularly if ground transportation is hampered by quake-compromised exits. This affects ambulance service, which as expected, was disabled or overwhelmed.
There is a gasoline restriction in effect now, so topping off emergency vehicles only was done. Citizens are limited to 10 liters, many stations are closed. We have restricted power times in the community, with two four-hour power shutoffs per day announced this morning. No one is complaining about this at all.
My hospital got an exemption, and we will remain on the grid unless there is an unforeseen circumstance and if so, we will shift to co-generated power which will allow us to remain operational.
As you might know, there have been two explosions in one of our nuclear power plants in Fukushima and another reactor in trouble. There have been refinery fires as well, so everyone is doing their part to save energy. A big concern is reactor meltdowns, which will be catastrophic.
We offered our medical services to the USS Ronald Reagan and other U. S. Navy ships here or steaming in this direction if they want bilingual physicians and medical interpreters to coordinate helicopter transfer to hospitals standing by to assist. I told military representatives that we have a 100+ bed capability but basically would accept patients 24/7 if they can be airlifted to our 24/7 heliport. U S. Embassy officials notified of our cooperation.
Unfortunately, in this perfect storm combination of a magnitude 9.0 quake and an up-to-10-meter tsunami, most persons lost or unaccounted for will not be casualties, but will be part of recovery operations as we are more than 72 hours post-tsunami. Aerial photos show no life in some areas where entire towns have disappeared. Waters have yet to recede. News is reporting 2,000+ bodies found in Miyagi prefecture yesterday morning. This figure is expected to top 10,000 very shortly as waters recede, and that number will undoubtedly climb.
Some hospitals in and near the affected areas are either overwhelmed or not functioning. One has 410 patients and cannot move them due to lack of open roads, and they are short on generator fuel, IV tubing for renal dialysis patients, and have little water. They are just one of several in big trouble but cannot communicate their need adequately in the myriad of requests being made to a stretched-thin disaster recovery effort.
As of this morning, we have not received a single casualty from the affected areas in spite of our early indication that we are 24/7 ready, willing, and able. This is not a criticism, but speaks to the difficulty in getting needs met in a disaster of this magnitude.
We are very, very lucky not to have sustained any structural damage in spite of the quake strength. Our fingers are crossed, so to speak, that aftershocks will cease and no further quake/tsunami damage will occur and that the nuclear reactor conditions can be resolved. This is a lot to think about. Recovery and clean-up are unimaginable at this point.
It almost goes without saying that there is no panic, people are orderly and compliant with authority, there of course is no looting which is unimaginable in this society.
John
Wednesday, March 16
More explosions and fires in the reactors. We received 4 radiation-exposed patients. They were local residents visiting in affected areas. At 25 km from the Fukushima plant they had low-level exposure. On arrival a small boy had low-level radiation detected in his hair, in spite of being decontaminated prior to arrival here. Mom had some on clothing. Bagged all clothes, fully decontaminated, and released to home. Scary.
Several big aftershocks today, magnitude 6.0 and more; creaking and groaning of the building I am in, and one lasted a full minute. This one located on land, much closer to us. It appears epicenters are moving south and some, although linked, are not directly related. Scary.
We marked all power switches with green sticky dots to key them as nonessential. Basically working in natural light during the day in all non-clinical areas. Rationing foodstuffs in hospital convenience store today.
Marathon 5-hour meeting today to determine how to add another shift or expanded renal dialysis for patients who unhurt, were evacuated beyond the 30-km limit of the nuclear plant. Not easy. We may need to borrow staff from non-functional dialysis facilities and house them here. We currently have more than 130 dialysis patients per day. Bumping that to 150+ is not easy. May need extra supplies. We are accepting 50 renal dialysis patients tomorrow afternoon from outside our area. Of these, 20 will be immediately admitted, and then we will shift some to our two satellite renal dialysis centers once stable. Thirty will be seen as outpatients three days a week, and temporarily will be housed in Horizons Hall atop the K-Tower in the medical center. Later they will be shifted to a line-of-sight hotel which has agreed to providing accommodations. This will prove challenging for both the patients and staff.
Notified today that we have will have critical shortages in some J&J products and Becton Dickenson insulin needles, 31Ga, 5mm length. Manufacturing plants in the affected areas have sustained damages. I need 140,000 of these needles, 70/pack X 2000 packs, but both UPS and FedEx are blocked from shipping to Narita and Haneda due to excessive volume being experienced. Blockages are lifted now and then when volumes are less than peak. I have J&J critical products on the loading dock in Singapore. UPS cannot ship. This is bad news and I am looking at alternatives. Kintetsu Express may be able to work around the blockages, so we are in contact with them. I have asked Swedish Medical Center in Seattle to look at sourcing for the needles for us. Unfortunately, Terumo needles are not interchangeable. Also J&J Cidex Plus and Cidex OPA disinfection agents, need 60 and 20 cases respectively, 4 one-gallon bottles to a case.
Frustration: Narita remains blocked. No provision for urgent medical supplies, to my knowledge. May ease soon?
Gas is rationed. Some staff living 50 km away may not be able to come in every day. Our new construction was halted. No gas to get materials to site and some staff cannot commute due to lack of gasoline. Refinery fire was close to us. Still burning. The fireball you saw on TV lit up the night sky. Not all train lines are open.
An insignificant note: My daughter’s goldfish died because the 4-hour power outage stopped the pump. When she told me, I thought of renal dialysis patients, sleep apnea monitors in homes, and pressure-sore mattresses. Life is very, very hard.
John
Thursday, March 17
Accepted 50 renal dialysis patients from Iwaki City, Fukushima Prefecture today. We are at 125 dialysis patients a day!
View more photos.
Photos courtesy of John Wocher