Training of Japanese Disaster Medical Assistance Teams (DMATs) began in 2005. Unlike DMATs from the Unites States, Japanese DMATs work in teams of 4 to 5 persons. The team members include doctors, nurses, and logistics personnel, often from the same hospital. Japanese DMATs are small because emphasis is placed on readiness for quick mobilization after a disaster. Consequently, their activities in the field are limited to 48 to 72 hours. A feature of the Japanese DMAT training program is its breadth, covering operations that deal with nearby or local disasters that occur near hospitals to those that deal with natural disasters that affect large areas.Reference Kondo, Koido and Morino 1 Japan is characterized by a large number of earthquake disasters, so many lectures and simulations assuming earthquakes have been incorporated. After the Great East Japan Earthquake that occurred on March 11, 2011, more than 340 Japanese DMATs were active for 10 days. The various lessons learned from the experiences of the DMATs in this earthquake disaster revealed changes that were needed to the existing Japanese DMAT training program. Current DMAT members received updated training based on the revisions.
METHODS
The Working Group of the Japan DMAT Investigative Commission, Ministry of Health, Labour and Welfare (MHLW), was organized to revise the training program. The members were medical doctors, nurses, and emergency medical technicians involved in regular emergency and disaster medicine.
First, the problems with DMAT activities during the Great East Japan Earthquake were investigated from the following materials: 1) reports that recorded the activities of DMATs throughout Japan after this disaster (kept at the Japan DMAT Secretariat National Hospital Organization Disaster Medical Center, Tokyo, Japan), and 2) academic papers that covered DMAT activities. A search was conducted by using PubMed (National Library of Medicine, Bethesda, MD, USA) and the Ichushi-Web (NPO Japan Medical Abstracts Society, Tokyo, Japan) for the years 2011 and 2012, with “DMAT,” “the Great East Japan Earthquake,” and “medical transportation” as key words.
Next, the currently issued DMAT training program was carefully examined, and a revised program was developed on the basis of the results of the above investigation. New and useful content was proposed and added. Inappropriate or unnecessary content was identified and removed. Topics that require longer times were suggested, and the time was increased. Topics with redundant or similar content were combined and reorganized. A new program was proposed under the condition that the total time for the training not exceed that of the existing program.
Analysis
Additional information relevant to but not included in the current training is described here.
Even hospitals that do not collapse from damage caused by an earthquake will become isolated if utilities are disrupted over a long period or the supply of materials is insufficient, and patients at these hospitals need to be moved to other medical facilities or evacuation centers by various means.Reference Anan, Kondo and Morino 2 DMATs provide hospital support to complement the functions of damaged hospitals.Reference Anan, Kondo and Otomo 3 When hospitals within a disaster area have DMATs, it is expected that these DMATs can start operations soon after the disaster occurs, and that support teams can implement their operations more smoothly.
The response to the Great East Japan Earthquake required DMAT activities over a period longer than 48 to 72 hours because of the large-scale damage across a wide area.Reference Uehiyama 4 Several teams withdrew when the time scheduled for their activities elapsed. The loss of a medical team in a location that still has medical needs can give rise to major confusion.
During evacuation of Ishinomaki City Hospital, rescue operations were done with Self-Defense Force (SDF) helicopters with support from helicopter ambulances and DMATs.Reference Anan, Kondo and Morino 2 Characteristic safety management and methods of communication associated with boarding and deboarding small helicopters is important.
The current program includes training on only wide-area transport of severe trauma patients. In this earthquake, however, greater percentages of patients with endogenous and chronic diseases were moved by wide-area transport, whereas trauma patients with high degrees of urgency or severity were moved short distances by helicopter ambulances.Reference Yano, Hayakawa and Suzuki 5 , Reference Yamanouchi, Inoue and Yamada 6 Furthermore, patients with a variety of injuries and illnesses were transported to the staging care unit (SCU) from the sites where they were rescued or from evacuation centers. Because of the scale of the disaster, patients in different disease states were transported by use of different methods to various places.Reference Yano, Hayakawa and Suzuki 5 , Reference Yamanouchi, Inoue and Yamada 6
Even for a huge disaster like the Great East Japan Earthquake, there is only one report of confined space medicine (CSM) being used, and that was to alert people to its danger rather than to describe its efficacy.Reference Matsumoto, Motomura and Hara 7 Therefore, training related to CSM was removed.
Even though Japanese DMATs comprise 4 to 5 members, multiple teams come together to form a large organization during their activities. In this situation, an emergency medical information system (EMIS) is an essential information-sharing tool.Reference Moroe, Ninomiya and Kuno 8 The Great East Japan Earthquake served as an occasion to move ahead with modifications for an enhanced EMIS. Given the importance of this system, the time for EMIS training was extended.
RESULTS
The current program is shown in Table 1, with the number (#) for each revised point shown in the right-hand column. Questions on hospital evacuation were added to the simulation in Lesson 14, and the time was increased (#1). A new desktop simulation was established that includes content on the initial activities that should be carried out by DMATs within damaged hospitals and content on information sharing and collaborative activities with external DMATs that come as support (#2; new lesson, not shown in Table 1). Questions and discussion on the conditions for DMAT withdrawal were added to the simulation in Lesson 14 (#3). A new lecture on precautions during activities on board small helicopters was also added (#4; new lesson, not shown in Table 1).
Table 1 Existing Japanese DMAT training programFootnote a
a Content of the existing program and points that should be revised. The revision point number is the same as the number in the Results section. CSCA indicates command and control, safety, communication, assessment; DMAT, disaster medical assistance team; MHLW, Ministry of Health, Labour and Welfare; SCU, staging care unit; TTT, triage, treatment, transportation.
Selection criteria for wide-area transport patients, in which patients with severe trauma, severe burns, or crush syndrome are the main candidates, were removed. The lecture in Lesson 17 was changed to include information about patients with a variety of pathological conditions such as endogenous and chronic diseases as candidates for wide-area transport. Patients in severe medical situations are managed with consideration of quickly selecting transport to nearby medical facilities that have maintained their functions. This transportation is carried out by various means, including helicopter ambulances and ambulances. Practical training about selection and treatment methods at emergency base hospitals and SCUs, by use of the simulator in Lesson 18, was also changed (#5).
Lesson 24 “CSM,” a classroom lecture on CSM, and Drill 1 “CSM” were removed. The content on coordinating with firefighting organizations handled in Drill 1 was modified and added to Drill 2 “Disaster site first aid station” (#6). The time for Lesson 11 “Practical training in EMIS” was increased (#7).
The content of Lesson 21 had some overlaps and so was merged with Lesson 22 (#8). Four lessons (20, 23, 25, and 26) on related organizations (police department, fire department, Japan Coast Guard, and SDF) were reduced to 2 time slots, and the lectures were reduced to 2 organizations each time in rotation (#9). Lesson 2 “CSCA” (Command and Control, Safety, Communication, Assessment) and Lesson 3 “TTT” (Triage, Treatment, Transportation) were merged, and the time was shortened (#10). Lessons on triage, Lesson 5 “Triage 1 (lecture)” and Lesson 7 “Triage 2 (writing tags, triage desktop exercise),” were merged and the time was shortened (#11). Lesson 19 “Treatment guidelines during disasters” was removed because it duplicated content taught in other lectures (#12). The new program was designed to have a total time of 2165 minutes, which was less than the 2205 minutes for the existing program (Table 2).
Table 2 Proposed new Japanese DMAT training programFootnote a
a CSCATTT indicates command and control, safety, communication, assessment, triage, treatment, transportation; DMAT, disaster medical assistance team; MHLW, Ministry of Health, Labour and Welfare; SCU, staging care unit.
DISCUSSION
Based on the experiences of the Great Hanshin and Awaji Earthquake in 1995,Reference Ukai 9 Japanese DMATs are required both to have the mobility to act as a quick response team and to be self-contained. However, if either mobility or self-containment is emphasized, the other may not be satisfactorily met. Hence, the activity period for Japanese DMATs was established to maintain a reasonable balance between the two requirements. In large disasters such as the Great East Japan Earthquake, however, the activities of DMATs are extended over a longer period. While firmly maintaining that one team will be active for the conventional short period, overall Japanese DMAT activities can be conducted over longer periods with deployment of second and third teams as replacements.
Changes in the DMAT education content were brought about by the substantial changes in social circumstances that have occurred since the establishment of Japanese DMATs, and the excessive bias toward the Great Hanshin and Awaji Earthquake in 1995 in the initial references to actual disasters. For example, CSM education was adopted because of the large number of injured or ill people in collapsed houses who were difficult to rescue.Reference Kondo, Koido and Morino 1 , Reference Tanaka, Oda and Iwai 10 These activities are extremely risky and should be carried out only with sufficient training. However, the time for teaching CSM is very short in the existing program, and acquiring sufficient skills with such little training is impossible.
Moreover, helicopter ambulances were not in use in Japan at that time. It was thought that the number of deaths in disasters could be reduced by transporting patients by use of aircraft to places far outside the disaster area. Thus, the government took the lead in developing a wide-area transport plan to transport patients long distances by using SDF aircraft. According to investigations following the Great Hanshin and Awaji Earthquake in 1995,Reference Tanaka, Oda and Iwai 10 the main candidates for wide-area transport are patients with severe trauma, burns, and crush syndrome. However, unlike the situation when the wide-area transport plans were developed 10 years ago, helicopter ambulances are now stationed throughout Japan. With this deployment, helicopter ambulances can be assembled when a disaster occurs to allow the option of air transport over shorter distances from the SCU.Reference Yamanouchi, Inoue and Yamada 6 This early transport plan laid the foundation for development of a more practical patient transport system.
A network exists that uses EMIS via the Internet to share information on hospital disaster situations and DMAT activity status. It is very important as a medical information-sharing tool during disasters in Japan. Information on situations that should be considered in hospital evacuation, such as building collapse and utilities disruption, is obtained as basic EMIS information. Given the disaster circumstances in Japan, which has many earthquake disasters, emergency base hospitals nationwide are being made earthquake-resistant or seismically isolated. However, long-term disruption of electricity, gas, and water utilities following the Great East Japan Earthquake left these hospitals with no prospects of short-term restoration. Some hospitals were unable to continue providing medical care. In the case that either a building collapses or utilities are disrupted, DMATs must be deployed immediately to support inpatient evacuation activities. If this is not done in an organized fashion with continued treatment during transport, patients’ lives could be put at risk. In Japan today, DMATs are the entity best suited for these activities.
The training of Japanese DMAT members is progressing year by year, and the number of medical institutions with DMATs is increasing. According to an official notice from MHLW, emergency base hospitals at 650 locations nationwide will need to have DMATs. Hence, DMATs are not only dispatched to disaster areas for support but also conduct their own initial activities when their own hospitals are hit by a disaster. The environment will continue to be developed so that they can operate smoothly in conjunction with outside support teams. In this way, a strategy is emerging in which a network of DMATs will spread throughout Japan and conduct rapid-response disaster medicine. DMAT education and training is important in preparation for the large earthquakes that are predicted to strike Japan in the coming years.
This study had the following limitations. A vast number of people participated in this disaster, and reports were presented at various conferences. As a result, we may not have reviewed all the reports and articles on DMATs. Second, the working group members who participated in the study were mainly authorities involved in Japanese DMAT operating plans, and subjective elements cannot be ruled out.
CONCLUSIONS
Analysis of experiences in the Great East Japan Earthquake revealed insufficiencies in the current Japanese DMAT training program and content not suited to current situations. On the basis of this analysis, a new revised Japanese DMAT training program was proposed.
Acknowledgments
This research was supported by the Japanese Ministry of Health, Labour and Welfare.
