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Methods on How to Cope Effectively with the Increasing Demand for Emergency Services
X City Fire Headquarters, X Prefecture, Japan
It has been almost 80 years since Fire and Emergency services was established in X in 1934 and almost 50 since founding legislation (Fire Services Act, Article 2, Section 9) was written. The ambulance’s characteristic siren has become familiar to residents and associated with the saving of lives. The image of emergency transport as merely a fast way to deliver patients to hospital has given way to the current reality of emergency transport personnel that double as practitioners of specialized knowledge and skills during transport to hospital.
2. Present State of Emergency Services
Due to recent demographic shifts such as low birthrates, an aging population and family nuclearization, the number of emergency service dispatches is steadily increasing. Last year’s total was the highest on record. It is predicted that this year is also on track to surpass last year’s total, and if current trends hold, future demand for emergency services will stay on the increase.
In 2011 there were approximately 5,700,000 dispatches across Japan, an increase of 240,000 (4.4%) from the previous year. Currently, there is an ambulance dispatch somewhere in Japan every 5.5 seconds. This is similar to X city’s rate of increase, 2011 saw 3,326 dispatches, an increase of 156 (4.7%) from the previous year. There are numerous incidents of severe cardiopulmonary arrest in which the degree of emergency is doubted by the patient, and dispatch is called instead of a taxi to the emergency room. Patients that are non-emergent and not in need of hospitalization make up approximately 50% of cases nationwide, and 60% of cases in X city. (Table 1)
Table 1: Summary of Emergencies: Nationwide vs. X city
# of dispatches 2011 change from previous year percentage change (increase) percentage non-emergent patients
Japan approx 5,700,000 approx 240,000 ( ) 4.4% ( ) 50.4
X city 3326 156 ( ) 4.7% ( ) 59.2
Source: Emergency and Fire Summary, 2011 (Ministry of Public Services, Fire Department), X City Emergency and Fire Summary, 2011
3. Issues to be Resolved
A. Response time delays
Increases in the number of ambulance dispatch requests raise the likelihood of requests backing up within jurisdictions. When this occurs in X city, dispatches are made from separate emergency departments, but response times are delayed as a result. This delay can be fatal for a patient suffering from cardiopulmonary arrest, or one with life-threatening injuries or illness. In 2011, cases of increased response times numbered 500, and of those, 50 cases had a high emergency severity rating, and 178 cases were rated as intermediate severity. Overall, there were 288 dispatches of high emergency severity, and 1,230 of intermediate severity or higher, and response times were delayed in 17% of high severity and 14% of intermediate severity dispatches.
There are three stations in X: Headquarters, Station West and Station East, but out of these, 77% of dispatches occurred within the Headquarters jurisdiction. This station sees much request backlog, with most of these being emergency personnel from Station East (there are situations in which, per control room decisions, an additional ambulance staffed with personnel also trained as firefighters is dispatched to backlogged Headquarters’ requests of high severity). Responses that originate from Station East to Headquarters jurisdiction number 354, with a confirmed delay of about three minutes. Next highest were responses from Station West jurisdiction to Headquarters, at 76, with a confirmed delay of about four minutes. Besides these, responses originating from Headquarters to each station had a confirmed delay of about 4 to 5 minutes. The delay of responses from Station West to Station East exceeds 4 to 5 minutes.
(Map 1, Tables 2-1 to 2-3)
As outlined above, this increase in the number of emergency responses invites delay of response due to request backlog, and is a cause of site arrival delays. Because of this, there are incidents in which the race against time for the life of the injured person is lost. Actually, it might have been lost from the start. Even now, 17% of high severity injured patients experienced delayed response times, and with predictions of requests for emergency services to increase on into the future, a rising probability of lost lives of critically injured parties is feared. At this rate, the brake on numbers of requests will fail, and it is predicted that the rate at which human damage is incurred will also rise. In order to save the lives of city residents, we would like to make sure everything possible is done to avoid these conditions.
Table 2-1: Summary of Headquarters Dispatches
Origin Jurisdiction Site Arrival Time Total # of Dispatches High Severity Cases Intermediate Severity Cases
Headquarters HQ 4:37 2135 188 768
Station West 10:51 36 0 15
Station East 10:21 21 3 11
Source: X City Emergency and Fire Summary, 2011 (excerpt)
Table 2-2: Summary of Station West Dispatches
Origin Jurisdiction Site Arrival Time Total # of Dispatches High Severity Cases Intermediate Severity Cases
Station West HQ 8:29 76 5 22
Station West 5:40 471 39 196
Station East 10:59 6 1 0
Source: X City Emergency and Fire Summary, 2011 (excerpt)
Table 2-2: Summary of Station East Dispatches
Origin Jurisdiction Site Arrival Time Total # of Dispatches High Severity Cases Intermediate Severity Cases
Station East HQ 7:43 354 40 128
Station West 14:05 7 1 2
Station East 6:29 220 13 86
Source: X City Emergency and Fire Summary, 2011 (excerpt)
B. Ambulance services are not free, but drawn from a wide array of taxes
When dialing 119 [Japan’s version of 911], a certain percentage of the population remains under the impression that ambulances arrive quickly to provide transportation to the hospital free of charge. But is it really free? In order to manage ambulance services, the city administers taxes, employs staff and carries out vehicle maintenance. In X city there are 11 full time ambulance staff members, and at least 14 that are trained as ambulance staff and firefighters, and four ambulance units. Expenses for equipment and fuel, skills advancement and training are all supplied by city taxes paid by residents. This amounts to 110,000,000 to 120,000,000 yen [approximately $1,220,000 to $1,330,000]. When this is divided by the gross number of dispatches (approximately 3,000), each incident costs approximately 35,000 to 40,000 yen ($389 to $444) of tax revenues. City resident taxes fund ambulance dispatches, and it is doubtful that residents are aware that dispatch expenses are such a heavy tax burden. If the number of emergency dispatches increases further, it goes without saying that not only will personnel and payroll expenses mount, but the fleet will experience quicker aging, medical equipment and supplies, and the budget for fuel costs will expand even more.
4. Investigating Possible Solutions
A. Raising resident awareness
Despite the fact that population growth is negligible, the number of emergency medical requests continues to rise, as described above. Is it really true that each year sees an increase in serious medical patients among city residents? Actually, 60% of transports are for non-serious patients and do not require hospital admission. A sense of entitlement is on the rise among city residents, and a certain percentage seem to think that designated emergency hospitals are there to perform even routine medical exams 24 hours a day, 365 days a year. There are patients who request dispatch at night or on weekends, in spite of non-emergent symptoms, and expect a mere routine examination, they see an ambulance ride as just a quick way to get to hospital and get seen by a doctor. Or, if it doesn’t work out, a lawsuit or claim for compensation might be in order. These are what are called the “monster patients.” Their actions exhaust doctors and nurses and deplete hospital coffers.
The following examples represent a certain portion, though not all, of emergency transport dispatches:
• Bug bites (with fingertip redness)
• Infant child’s not acting normal (mother not able to provide further explanation)
• Requests related to anxiety-induced discomfort in the elderly (repeated requests from a single patient)
• Requests for doctor appointments in lieu of other transportation to the hospital, so patient can be waiting outside their residence with bags packed (common among the elderly)
• Requests for medical treatment due to motor vehicle accident, without injuries, but “just in case.”
• Requests from law enforcement post motor vehicle accident investigation (approximately one hour after the incident, and where the patient is able to walk unassisted)
• Requests from school staff in which a student was cut with a small amount of bleeding. Emergency request is made only to document the incident
As we can see, we can see that requests for medical services of doubtful emergency are common. However emergency personnel are not able to turn away these types of requests. Even patients with extremely mild injuries need some kind of assistance, and their needs should be taken into consideration. Without this, a viable solution will not be possible.
B. Elderly oriented community medicine
The population of X city as of 2011 is 115,061, with 16.1% senior citizens. By 2015, there will be a predicted population of 113,252, with 19.7% senior population rate. (Table 3) It is easy to see that we are moving in the direction of an aging society.
Up to now, Fire and Emergency Services has not often set foot in the territory of elderly community medicine. This has been the province of management in the municipal welfare department. However, it is absurd that within the same city there is no protocol for interdepartmental cooperation. In the future, it appears that there will be a need to construct a system that deals with community medicine via this type of interdepartmental communication. We think that through the building of a community in which the elderly lead healthy and robust lifestyles will reduce emergency calls among this part of the population. For example, the welfare department implemented a policy to improve the health and vitality of the agency’s elderly (Relief Plan 21), and then, in collaboration with Fire and Emergency Services, emergency medical treatment and fire safety education for the public is being carried out.
Table 3: X City Population and Expected Percentage of Senior Citizens
X City Population Percent Senior Citizens ( 65)
2011 115,061 16.1%
2015 (expected) 113,252 19.7%
Source: X City Homepage (excerpt)
C. Organized cooperation and collaboration with hospital doctors
In 2011 there were 248 patient transfers between hospitals, accounting for 8.2% of total ambulance dispatches. For X city, often the destination hospital is not located within the city but actually in X or the X area. With the transport itself taking one hour, the roundtrip from dispatch back to the point of origin may total two or three hours. During this time, emergency services requests are likely to multiply and back up, becoming a major cause of delays in site arrival.
The choice to use an ambulance, private medical transportation or another method for hospital transfers is presumably a decision made between the family and doctor. In an emergency, it is thought necessary to protect the patient’s life that the patient be transferred to a designated high level emergency hospital, but this involves the temporary cessation of medical treatment and also the actual transport and transfer, among other things. There is a persistent trend that only during emergencies and with the doctor’s recommendation is ambulance transport utilized.
Moreover, hospital admittance is also determined by the doctor. Locating a specialist in an area of medicine to the condition of a patient with a certain condition can be especially troublesome at night and on weekend transports. For every doctor admitting emergency room patients with a wide variety of conditions, there is another specialist who will not admit any patients outside of their specialty area or field. As much as possible through trainings and clinical conferences and meetings, emergency personnel want to get to know doctors on a sight basis, and by developing a relationship of mutual trust, realizing the ideal goal of quick hospital admittance. If this is accomplished, the time up to admittance is cut down, and with a quicker trip back to the station, personnel might also be able to evade the backing up of ambulance dispatch requests.
D. Investigations into a fare-based ambulance system
As described above, despite the fact that ambulance funds are drawn from a wide array of taxes, since no money changes hands directly from the residents that use ambulance services, it is easy to think of services as free. Private ambulances, private patient transport companies and organizations charge fares, and city residents must pay up-front. Looking at it from the patient’s point of view, one presumably would choose an ambulance because they don’t directly pay to ride. However, as ambulance requests steadily rise, in order to put a brake on non-emergency use, it might be wise to take the switch to a fare-based system into consideration. There are many matters for investigation regarding ambulance fares. The biggest issue that might arise is the hesitation of people with an actual need for ambulance, their symptoms worsening, and the possibility of death. To lose lives as a consequence of public policy meant to save those lives would be a cruel twist of fate. There is a need to investigate and inquire more deeply into problems raised by a possible fare-based system, and into which method can be most effectively conducted by emergency services.
5. Policy of other cities and organizations
A. X city Fire department policy
The X Fire department introduced the nation’s first call triage system. Call triage is a system in which 5 levels of emergency and condition severity are identified during the 119 call, and matches the patient’s needs with appropriate emergency personnel. Also, in the event that dispatch has been deemed unnecessary, transfer can be made to the telephone emergency consultation desk with caller consent. For injuries identified as extremely slight, a two-person ambulance dispatch can be sent (authorized by the national Special Zones for Structural Reform Act). This is reduced from the usual three person team, so that one remaining emergency personnel can pair up with a member of the Fire department to form another emergency team on standby. When handling multiple calls for assistance, emergency services teams are dispatched from the nearest possible station in order to avoid site arrival delays, and administer emergency treatment on the way to the hospital. The vehicles are equipped with emergency equipment with trained personnel onboard. Because ambulances are dispatched from locations outside their jurisdiction, there are late arrivals, but they are the first to arrive on scene and provide early stage emergency treatment.
One more characteristic of call triage is that no matter which dispatch officer takes the call, the level of emergency and condition severity will be the same. With just the input of the caller’s reported information into a computer, triage level is identified automatically. Dispatchers that take calls undergo 140 hours of training, so that no matter which staff member takes an emergency call, the triage level decided will not differ.
The introduction of call triage has served as a way to effectively utilize X’s actual ability to fight fires and perform emergency services, and is avoiding site arrival delays through the implementation of the Special Zones for Structural Reform Act and emergency services personnel teams.
B. Tokyo Disaster Prevention and Emergency Medical Service Association’s Policies
The Tokyo Disaster Prevention and Emergency Medical Service Association operates a private emergency transport service and Support CAB call center. This refers to a nongovernmental enterprise that manages emergency vehicles not authorized to go on emergency runs, and they are equipped with stretchers and emergency medical equipment like oxygen. The crew present during transport is comprised of trained nurses and emergency medical technicians, and fare is determined by travel and transport time, often running into the tens of thousands of yen [hundreds of dollars]. Support CAB is a taxi service with similar rates to regular taxis, staffed with crew that have completed emergency training courses and equipped with a defibrillator.
The call center operated by the association covers all 23 wards of Tokyo plus the Tama area. Associated parties include 76 private emergency transport services businesses with about 180 vehicles, and two Support CAB centers with thousands of vehicles. The call center handles 200 to 250 cases per month, with 80 related to private emergency transport, 30 related to Support CAB, and the remaining calls being inquiries. However, calls to the center have showed a downward trend from year to year, and the number of patients that choose the less expensive Care taxis over private emergency transport is increasing.
For instance, the users of private emergency transport services that the association handles number about 300 per year, but most of these are repeat callers from the upper levels of society. The calls being routed to the transport service by the call center are declining because these repeat callers tend to call the office directly. A public relations campaign to develop new customer markets is necessary, and the main activities being conducted currently are listed below:
1. Participation in disaster prevention training
2. Participation in the New Year’s Fire Brigade Parade
3. Positioning 20 emergency transport vehicles every 5 km (3.1 miles) along the Tokyo Marathon
4. Utilizing televised media
A public relations campaign is being conducted at events like these, but even more publicity is needed. Also, another area to focus on would be reforming the system through actions like the writing of legislation dealing with the use of private services for hospital to hospital transfer of non-emergency patients. This might also, through reducing the difference in fare rates between ambulances and private emergency transport, encourage patient use of such (private) services, and put a brake on the number of ambulance dispatches.
6. My Proposal
Plans to improve emergency life-saving programs run the gamut, and it is impossible to put all of them into place at once. However, it is imperative that we increase the number our cooperative partners and make consistent forward progress, even if it is done piecemeal. We must do whatever can be implemented at Fire and Emergency Headquarters, with the engagement of all city governmental departments and apply pressure to wider regional, prefectural and national governments.
I put together the following table of possible strategies.
Table 4: Table of Solution Implementation Plans
To Be Implemented at X Headquarters
With X City Cooperation Pressuring Regional, Prefectural, National Gov’t Structures
Current Fiscal Year – next Fiscal Year Effective use of fire fighting
Resident focused public
relations campaign Strengthening support for
welfare dep’t cooperation
Strengthening support for
Strengthening support for
teacher cooperation Development of outside Fire
(increase numbers of cooperative partners)
Beyond next Fiscal Year Setup of consultation
Operation of Support CAB
Partnership with Care Taxi
Carry out problem resolution
with welfare department,
hospitals and schools Conducting a factual
investigation with partners
with the goal of problem
Long-term Research into ideal methods of community medicine
Research into ambulance fare systematization Proposal based on results of ambulance fare system research
A. What can be carried out at Fire and Emergency Headquarters?
1. Efficient Use of Current Firefighting and Emergency services power (emergency personnel utilization)
In order to avoid delays in site arrival, emergency medical personnel are put to use. Emergency medical equipment is installed into an emergency vehicle, and for high severity requests that are backlogged within a jurisdiction , Fire and Emergency act as first responders, arriving from the local station to perform emergency first aid. During that time ambulance from an outside jurisdiction arrive and work in concert with the first-responders for patient ambulance accommodation until hospital transport.
If X city emergency personnel utilization is possible, the pump, fire and rescue teams would all have to be stationed at Headquarters 24 hours a day and at Station West during the time that the station Chief is on duty. Station East would not be plausible, as emergency personnel dispatch would leave the station house unmanned. With this utilization in mind, emergency medical personnel were able to execute it in 45 of the 50 cases of severe emergency dispatches with delayed site arrival in 2011. X city also excels in personnel efficiency, and while this doesn’t mean that there won’t be cases of delay, there is a move in the direction of carrying this out.
2. A resident focused public education campaign
In the past, standard education and development programs regarding emergency services requests that were aimed toward city residents consisted of only training classes on life-saving techniques. However, in order to increase the effects of public relations campaigns, Fire and Emergency Headquarters should act as a cohesive unit. Solutions to emergency demand should include not only how to deal with emergencies, but should also be thought of as involving Fire and Emergency Headquarters and the city as a whole. At Headquarters the prevention department manages all types of training meetings. The public management department is in charge of disaster evacuation leadership through conducting education and training programs, operating fire company focused education and training, different types of field trips and visitor education programs, and child education programs.
Through educational activities and events like training sessions and disaster training leadership, Emergency and Fire is of course a big hit with children, who wave at fire trucks that are even just passing by. This in itself is one of the program’s public benefits. Every year, kindergarten and pre-school focused activities bring in over 1,000 participants, and elementary school government field trips for fourth graders send around another 1,000 participants. These children and others like them go home and discuss their experience with their parents, which triples the results. Conversations with grandparents make that five times the original benefit. In this way, Fire and Emergency personnel use these opportunities of contact with city residents to educate and spread the word in order to maximize the results achieved.
3. Emergency consultation desk setup
Some calls to 119 are from individuals who are not sure as to whether they should request an ambulance. Currently, cases in doubt are handled by dispatch. However, there is a need for setup of a specialized emergency consultation system to which cases that are found not to require ambulance service can be referred. Calls referred here would not be only 119 calls, but even ones from a representative of Fire and Emergency Headquarters, and if doctor and nurse calls are also made possible, many dispatches would be avoided by emergency consultation. For example, during the winter flu season, there are many calls regarding children’s fever treatment and hospital inquiries. The symptoms of a portion of these do in fact warrant ambulance dispatch, but many cases could be avoided through phone consultation.
4. Support CAB operation, private patient transport services, and partnership with Care Taxi
There will be a system set up to refer non-emergency patients who are able to walk, have decided their hospital, and have given consent, to city Support CABs from their 119 call. Crew members will have completed emergency training courses, and vehicle will be required to carry a defibrillator.
For non-emergency patients who are unable to walk and have given consent to use either Care Taxi or private transport services, referrals will also be made to the nearest provider company. If the patient’s condition makes a sudden change, a linkup system will be established in which an ambulance will be immediately dispatched to that patient.
Because in X city currently there is only one private emergency transport certified taxi company, a single consultation desk is jointly operated by Support CAB and private transport services. Taxi drivers receive training in life-saving techniques and each vehicle will be equipped with a defibrillator. Also, a hotline will be established as well as a public service announcement campaign performed, with the goal of using methods that lend themselves to widespread use.
A healthy relationship will be cultivated, meeting regularly; to move forward while taking on common problems together in cases that require cooperation, such as when Care Taxi has non-emergency patients requiring medical attention.
B. Plan Execution with the Involvement of City Organizations
In recent years, as Fire and Emergency organizations have enjoyed widespread growth, the number of departments that have merged with national government has increased. However, X city has not consolidated, and has independently managed all aspects of Fire and Emergency Headquarters operation in an environment of smooth communication with other city departments. The main hospital in the region, X City Public Hospital, is also under city management.
1. Strengthening Cooperative Structures with the Welfare Department (Elderly Services)
As per proposals for elderly emergency services, Fire and Emergency sends out personnel during Welfare department-run senior citizen meetings and events to make information available regarding emergency services and treatment. Fire and Emergency services along with City Welfare work together in dealing with issues related to senior welfare and emergency treatment. By developing a close bond through the holding of events such as study group meetings, both partners cooperate in developing a solution that helps preserve the relationship, while helping to build a community in which seniors can achieve peace of mind while leading healthful lifestyles.
Furthermore, women Emergency and Fire teams were formed in April 2012, and are carrying out fire prevention and emergency related public awareness campaigns. Currently, campaigns consist of publicity during events and leading training courses on life saving instruction, but policies being written currently will include performing home visits to senior citizens living independently. These home fire safety visits were originally carried out by Fire Prevention personnel with the cooperation of Public Welfare departments, but future plans call for female fire teams taking the lead role in place of Prevention in conducting visits with Welfare. Since female fire teams hold standard certification, they can also add information on the state of emergency treatment to the safety visit. It is anticipated that the results of simultaneously working with and spreading public awareness messages to Welfare department employees, who have many opportunities to speak with an area’s senior citizens will be substantial.
2. Strengthening Cooperative Structures with the Welfare Department (Public Health Workers Overseeing Child Care
The Welfare department is charged with handling cases regarding child care and support from pregnancy through pre-school, child and pregnant mother medical exams, as well as a childcare consultation desk. The staffer in charge is a Public Health employee and deals with both physical and mental health issues.
Emergency request cases having to do with this station often include child fever, child injury, and the mother’s mental health issues. Regarding these mental health cases, there is the possibility that patients will make multiple and repeated emergency requests. What’s more, if the situation escalates, so does the possibility of child abuse. The employee’s role here is a critical one, focused on care for the mother’s mental health and preventing unforeseen incidents. As Public Health and Fire and Emergency employees share information, cooperative structures and procedures that include proposals to deal with repeat callers are strengthened.
3. Strengthening Cooperative Structures with X City Hospital
This is the receiving hospital of approximately 60% of the total number of transport calls, and systems that encourage cooperation will be reinforced. Physicians will be requested to use proper ambulance procedures for patient transport between hospitals. Here again, doctor and nurse relationships and systematized cooperation will be bolstered, helping to ensure smooth operation from reception to hospital treatment.
X City Hospital is also one that conducts emergency medical technician training, and offers an environment in which it is easy to get to know people’s faces. Clinical conferences [in which Japanese EMTs participate] are held on an irregular basis, and cooperative doctors and nurses are also present. However, it is in doubt whether a continuing beneficial relationship is possible, so as the conference trainings are put on by the most collegial part of the doctor and nurse population, it turns into a situation such that when they leave or transfer, personal relationships die off.
In order to strengthen the partnership between X City Hospital and Fire and Emergency, instead of relying on the most cooperative doctors and nurses, the administrative office should play a more central role and begin organizing and holding regular training and clinical conferences. In this way, through dialogues about not only medical cases, but also toward solutions for points of contention and shared problems, beneficial relationships will be established so smooth and proper transport protocols can be realized.
Also, through widening our scope by taking such measures with neighboring hospitals, connections to community medicine solutions are also made.
4. Strengthening cooperative structures with teachers
X’s children are our future, and school is where they spend most of their time, much of it socializing and being together. The teacher is in charge, and it goes without saying that it is most effective to utilize them as conveyors of important information. Fortunately, the system has advanced to the point where teachers are emergency first aid certified, and currently each school has 1 to 5 such acting teachers. We would like them to demonstrate their proficiency, and to have the students understand not only emergency first aid, but also the current state of emergency treatment.
It is expected that the positive effects of these student focused public education campaigns will be multiplied through family discussion.
C. Execution with Regional, Prefectural and National Involvement
As we move to resolution of these issues, we simultaneously train partners from other Emergency and Fire departments and survey residential awareness of community medicine. That is why through dealing together with common issues that have come to light and the exchange of opinions between Fire and Emergency and supporters initiates the building of a foundation that includes research into a fare-based system. This aim of a fare-based system does not stem from financial tensions brought by reductions in the Emergency budget. The goal from the start has been to keep dispatch requests down. Just what do city residents think about this problem?
Practically speaking, we want to educate local residents about their community medicine and clinics. Because there is a slant to the opinions heard when listening only to emergency and fire personnel and city employees, it is thought that surveys on a wide variety of households, from rich to poor, from single tenant to family homes to senior citizens living independently should be taken. If that is done, the fact that the introduction of fares is not only an ambulance problem, but one of community health as a whole might fall into sharp relief. The goal is the resolution of these issues, working in concert with welfare and hospital departments. Toward this resolution, the following points of investigation for a fare-based ambulance system are under consideration:
1. Should fares be applied to all ambulance trips, or only to those not following proper transport protocol?
2. Establishment of proper and improper criteria
3. Appropriate fare rates
4. When/where to collect fares
5. How to best deal with hesitation because of fares on the part of residents in serious emergencies
There are still many points to be resolved regarding fare-based ambulance transportation, but with not only X city communication but also between prefectural and Osaka/X regional Fire and Emergency departments, we think that we must move toward solutions step by step, without rush.
Results can then be presented to prefectural and national governments, raising awareness from the regional to the national level, in order to change the thinking of city residents.
I have met many city residents on the location of the emergency. From site arrival to hospital delivery often takes more than 10 or 20 minutes. However, in this short period of time a myriad of human drama is represented. There are instances in which lives are saved miraculously, and also those in which lives are lost. Emergency personnel invest their hopes and fears into each day of their life-saving duties.
Even in that chaos, there are those cases that remain distinctly in memory. Of course there are pleasant cases, as well as ones that still vex because unnecessary loss of life might have been avoided. If arrival was just a bit quicker, if the call had come in just a minute sooner, they might be alive today. Even when ambulance personnel do all they can, sometimes it is not enough. How many times must we witness a family’s tears? How can this unnecessary loss of life be avoided?
Through this policy proposal I have resolved to slow down unnecessary emergency requests, reduce site arrival delays due to backlogs, helping to bring about unnecessary loss of life. This determination will be born through the start of my proposal.
Japanese to English: Emergency Preparedness in the Wake of Two Major Earthquakes General field: Social Sciences Detailed field: Safety
Translation - English Emergency Preparedness in the Wake of Two Major Earthquakes
X X, X City Fire Headquarters
I live in X prefecture, which was devastated by the Great Hanshin earthquake of 1995. 18 years have since passed, and while residents go about their daily lives here, exterior reconstruction has reached a point where almost no trace of the great earthquake remains. There is, however, a deep and lingering sadness in the hearts of those who live here.
Two years ago, on March 11, the 2011 Tōhoku earthquake caused extremely heavy damage, centering on the Tōhoku region. I was acting leader of the emergency fire aid unit in X prefecture at the time, and was on duty immediately after the quake at Minami Sanriku-chō in Miyagi prefecture. Additionally, I was able to visit Minami Sanriku-chō and Ishimaki city, in the same prefecture, five times in two years. As a result of the experience of listening to and observing a myriad of stories from Station Chiefs and disaster victims, I feel that the Great Hanshin earthquake was fundamentally different from the 2011 Tōhoku earthquake. After experiencing two high intensity earthquakes, I would like to make of record of my thoughts on how to keep damage to an absolute minimum should another one occur. I would consider it a job well done if this piece were put to use by the worldwide community to afford the avoidance of even a small amount of the potential havoc brought by certain natural disasters.
The content of this piece is about my stay in Miyagi prefecture, Minami Sanriku-chō and Ishimaki city. This is not a government issued or approved publication, but my own personal opinion.
2. Preparing for the Worst: Disaster Planning
The damage to eastern Japan from the earthquake was slight, while the tsunami damage was overwhelming and severe. When planning ahead, we must assume how many homes would be swept away in the event of a 30 foot wave surge, as if it were our own home town. It is necessary to map out the regions that would flood and get an idea of how many people live there. However, instead of a simple regional population count, there is a need for a certain degree of accuracy in estimate of population, separately for weekdays, weekends/holidays and nighttime. Based on the area, there are also regions in which weekday population numbers fall as residents leave to work in the city. Conversely, the population of a large coastal city might swell during weekdays. Population numbers at tourist destinations are presumably higher on weekends and holidays. In this way, the number of disaster victims will rise or fall based on the timing of the disaster event.
Here again we see the need to conduct research beforehand and based on those results, put together a plan to provide for the survival of all disaster victims.
3. Emergency Shelters
Next to be addressed is the establishment of each flooded region’s emergency shelters. Established centers should be located away from disaster-affected areas if possible and, even better, where relief supplies can be secured easily from surrounding cities and suburban areas. As for the scale of shelters, based on my experience, one for approximately every 500 people is advisable. This was impressed upon me through emergency work performed at two shelters in Minami Sanriku-chō. One of these was a 500-person middle school, and the other shelter was located in the town center general-purpose gymnasium, handling 2500 people (maximum occupancy 4000). The former was set up by community residents themselves. Administrative staff was sparse, and despite the interruptions in the lifelines of electricity, natural gas and water, there was the distinct impression of cleanliness, even the toilets. Regional leaders played a key role in establishing rules of conduct here, and the shelter seemed to be quite functional.
Due to the central location of the latter of the two emergency shelters, the mayor, Self-Defense Forces, and police and fire personnel were stationed there. I saw residents crammed and overflowing, with a certain segment making frequent reports to staff on the quality of living conditions. Sanitation left much to be desired, toilets were clogged with solid waste, and standing-room only conditions prevailed. Perhaps due to sheer numbers, it was not known who the leader was, and residents had the run of things. I recall images of crowds charging the relief supplies upon delivery to the shelter.
From these experiences, I do feel that a shelter accommodating 500 people or less is advisable, but accommodation levels can fluctuate daily, and are hard to estimate. People coming in to shelter include those separated from family and making the rounds at shelters looking for them, those hearing rumors of emergency shelter life, those who just need any small improvement in their living conditions, those who just can’t bear group living and go back to their homes, and those whose food has run out at home, and subsequently come to the shelter. Also worth noting is that people who take refuge at emergency shelters are not just residents, but people who were unlucky enough to be traveling or working in Tōhoku when the tsunami hit.
4. Partnering with Related Organizations
There were many groups active at the stricken areas of the Tōhoku earthquake such as the Self-Defense Forces, police and fire departments, as well as national and local government organizations. After the Great Hanshin earthquake, emergency drills and measures to strengthen cooperation were carried out in Japan. With the Tōhoku earthquake, I don’t know whether the Self-Defense Forces, police and fire departments, and command center administrative staff (at the national, not local level) were able to successfully coordinate with each other, but it is true that upon entering the area, cell phone transmission of information was impossible due to the suspension of service. Teams at each site were both unaware of other teams’ movements and unable to transmit information regarding their own movements. Each team was to more or less concentrate on a certain site. Staff at these disaster sites desperately felt the necessity of satellite phones.
Also, there was the problem of relief organizations’ fuel supply. Long distance ambulance transport was often necessary, and fuel reserves dried up quickly. At base camp, there was only diesel for fire vehicles. Gasoline was rationed on a negotiated basis at fill stations, and while most stations were damaged, the open ones were overwhelmed by civilians. Despite long lines, ambulance enjoyed priority status, and were able to refuel without queuing. From the civilian’s standpoint this was an inconvenience. The need for legislation allowing for the establishment of temporary, emergency vehicle-dedicated fuel filling stations became evident.
I feel that for the future resolution of problems like this, it will take more than the administration going it alone, and instead will depend heavily upon cooperation with the private sector. Administrative organizations have taken heavy damage, and they must enlist the help of specialists in given fields when their work gets too backed up. It is essential that a widely accepted protocol for coordination be set up. I have identified the following to be necessary for future severe earthquake preparedness:
a. Partnerships with Public Works and construction companies for the purpose of early stage traffic network reconstruction
b. Partnerships with phone companies for the installation of temporary antenna and satellite phone rental/lending, with the goal of early stage information communication network reconstruction
c. Partnerships with oil companies in order to combat the shortage of fuel for heating and vehicles
d. Partnerships with the manufacturers of daily supplies, foodstuffs and medical supplies
e. Partnerships with shipping companies for the distribution of daily supplies, foodstuffs and medical supplies
f. Partnerships with companies specializing in the construction of temporary housing
g. Partnerships with toy manufacturers and providers of entertainment products for help in easing the psychological and emotional strains of the emergency shelter
5. Medical Treatment
First, we must get an idea of approximately how many hospitals and clinics are in the region, as well as the number of patients admitted to them. Then it will be important to plan the evacuation and shelter of those patients. Also for medical facilities outside the flooded zone, treatment capacity levels will need to be estimated. In the event of a natural disaster, it is presumed that a large number of patients will surge at the disaster-designated hospital, and preparation for this will be key. Many victims’ daily medication was swept away by the tsunami following the Tōhoku earthquake, and want of medication for high-blood pressure, diabetes and other conditions became a frequent complaint to emergency personnel. After having lost their home, family or emotional stability to the earthquake, even daily medicine isn’t available. There has been a daily increase in the number of refugees whose health severely suffers from exhaustion and lack of sleep. I have heard reports of residents within walking distance of the hospital who rushed in to request medication from two to seven days after the earthquake. It is not only this, but the hospital also had to deal with emergency personnel transporting severely injured or ill patients, and police or Self-Defense Forces, waiting to perform autopsies on the recently deceased.
I have heard that the number of patients transported to the hospital was low on the day of the earthquake. The reason was that ambulance could not approach disaster sites, either because of sites being submerged, or, even if waters had receded, piles of debris blocking their path. Ambulance vehicles in affected areas had been swept away. Emergency and fire rescue teams from across the country entered the disaster-stricken area, and since the third day after the limited restoration of traffic by the Self-Defense Forces, even hospitals report being extremely busy.
During the time I was active, because cell phone service was not yet available, all patient transport and reception was conducted without communication beforehand. The system was set up for triage to be conducted upon hospital arrival by a doctor, who would assess the severity of the injury or illness inside the ambulance, and then send the patient for reception. There were also instances in which ambulance personnel had to form a queue several vehicles long. This recalls images of hospitals swollen past maximum patient capacity.
At the disaster-designated hospital for the latest affected area, only patient reception was being conducted, so the number of admitted patients climbed past maximum capacity. These patients had to be transported to hospitals located further inland. I have been told that it was a situation in which transport destinations were worked out based on physician networking and connections, and established before the earthquake. We see a need here for the adoption of standard protocol for patient reception.
Next were those patients receiving medical treatment at home. Dialysis patients must receive regular and consistent treatment, and home-care patients receiving oxygen cannot live in an environment where that oxygen has been rendered useless by a tsunami. The number of these patients in the region should be estimated in advance, and a plan drawn up that outlines how best to tackle the problem in a disaster event.
With the Great Hanshin Earthquake, there was a tendency toward a high number of casualties that resulted from crushing deaths, or crush syndrome, victims buried under collapsed homes. However, in the Tōhoku earthquake, the high number of drowning and hypothermia patients was unforeseen, and is considered to be characteristic of tsunami disaster events.
6. Regional Disaster Preparedness
After a high intensity earthquake occurs, administration, fire and police departments seriously overextend themselves when it comes to rescue operation capability. In the Great Hanshin Earthquake, many residences and other buildings collapsed, and citizens found themselves in a situation with no means of escape. Most of the rescues of residents who were trapped inside collapsed houses were saved not by police or fire department personnel, but instead by other residents of the same neighborhood. They would remove debris with bare hands to rescue those inside. I have heard that there were a large number of instances in which time ran out on collapse victims, who were unable to be saved.
This is the lesson that led to the formation of independent disaster relief organizations. When administration gets overloaded, the region’s residents work together and organize with the goal of taking it upon themselves to protect their own homes and land. They own a disaster emergency storage unit with crowbars, chainsaws, trowels, etc, and have assembled an array of rescue equipment. Regular training on equipment operation and emergency shelter setup is conducted. Tsunami evacuation training is conducted in coastal regions, and the organization comes up with how to evacuate the elderly and those with physical disabilities to higher ground. With the Tōhoku earthquake, depending on the region, these practices were held up as examples and certain areas have even experienced minimal loss of human life.
However, even more important is their formation of an interdependent community. A recent trend is an increase in the drifting apart of households from one another in neighborhoods, so that less is known about what kind of people live where among neighbors. A spirit of mutual help and aid has tended to weaken. In the actual event of an earthquake, information such as how many people live where or if elderly or disabled residents are likely to be home will be valuable to the rescue of any possible victims.
Each community organization can also operate emergency shelters. Through efforts such as the smooth handing out of daily supplies and food or even keeping things clean, this fixing of responsibilities in communal life can bring the benefit of easing mental stresses.
I hope to see these independent disaster relief organizations activities continue, thrive and improve.
7. Disaster Preparedness in the Home
High intensity earthquake disasters start with the quake itself. After that, there is the question of whether a tsunami will follow or not. In order to survive, it is important to stay free of injury arising from the earthquake. Inside the home, common causes of injury include things falling from above, and furniture tipping or falling over onto a person. What should be done to avoid injury? We would like everyone to consider doing the following:
a. Make furniture stationary
b. Don’t set things on high places
c. In the event of an earthquake, get under something solid
d. Prevent glass fall-out from above by setting glass items so they will not fall
After the actual quake, tsunami protection measures and home evacuation plans are next, however, even if the house does not actually collapse, there is the possibility that windows and doors will lose shape due to the quake, becoming unusable and increasing the chance of evacuation failure. There is also the possibility that the evacuation route will become blocked. So here I would advise that the following measures be carried out:
e. In the event of an earthquake, immediately open doors and windows for evacuation
f. Refrain from placing furniture close to room entrances. If it falls, escape becomes difficult
g. Always keep rooms free of clutter
Since the Tōhoku earthquake, I have been fortunate enough to share my experiences in many venues such as city businesses, administrative offices, schools, independent associations and organizations, and also had the chance to speak in Tokyo and the U.S. I received a lot of feedback from my audience, and consider myself fortunate to have those who cannot hear my words read them and share in the dialog on how to keep the damage and destruction from earthquake and tsunami disasters to an absolute minimum.
With my second experience of a high intensity earthquake, I witnessed the most miserable scenes. Earthquakes are inescapable. However, it is possible to keep damage to a minimum. If, as a result of my words, even a small amount of suffering is avoided, if there is even one person willing to listen to my story, I would go anywhere, any time to meet and share with them.
As stated in the beginning, this piece is one of personal expression and opinion, a commentary on what I have seen and heard. There are things about which I may very well be mistaken. If you are kind enough to read this, your thoughts and opinions would be much appreciated.
Thank you for reading this in its entirety.
Working to Reduce Preventable Deaths
Japanese to English: Hard Boiled General field: Art/Literary Detailed field: Poetry & Literature
I can’t explain why I thought so. There might have been little bodhisattvas or other statues here originally, and then might have broken. Someone might have taken them. I started to go with that. But it wasn’t right. No matter how hard I tried to deny it/what I thought, there was something, a thick floating mass of negative energy, piled in upon itself and permeating the air. It was such an ominous feeling that I just stood and stared. Looking closely in the center I saw about 10 jet black stones that looked like little eggs arranged in a circle. This also was extremely creepy. I took off at a quick pace, trying to avoid another look. This kind of thing used to happen to me every once in a while on trips. There really are haunted places in this world, and mere mortals should not get involved with them, if they can avoid it.
So then I got a good hiding place without making my presence known, and mom went out with a spring in her step. She was a beautiful lady in addition to having a passion for the hospitality field, so she never missed a day at the bar, which was her job but also for fun. She was doing the same in this town. She hadn’t gained weight, was still so little. She left quickly. I swiftly confirmed mom’s room number on the mail slot, and reached in the top-side. Yes, same as always, she had taped the key inside. I pulled it out, and made for mom’s new apartment.
”Yeah, I know what you mean. It’s a strange day. Back in the old days, they would say it’s a day that badgers come out. The air is heavy somehow, and the night is so dark. But, you know it’ll pass, even a night like this. And, you know what? That lady in the bathrobe you’re talking about?”
You know she appears every once in a while. Here. She tried to commit double suicide with her lover, but only she died. Her lover was a schoolteacher, he survived. He didn’t take enough sleeping pills. Y’know what then, he left town with his wife and kids.
“Oh, those flowers, those are from the guy I was just telling you about, the suicide attempt. He sends them. Every year.”
“Ah, the boyfriend of the girl haunting the upstairs you were talking about,” I said.
“Right, every year he says to please give these as an offering. But I can’t put them out on the front desk, can I? It’s bad luck. It was already bad luck from the start. But I can’t put them out as an offering in the rental room for that either. So I put them here. I do burn incense for her every day.”
“Is that right?” I recalled the woman’s lonely demeanor.
“Everyone is always like, ‘ghosts are soo scary,’ but, you know, the living are much scarier,” the manager warned.