CBBS Today

On March 11, 2011, a magnitude 9.0 earthquake and tsunami devastated the northeast coast of Honshu (Japan’s largest island) and triggered the explosive release of radioactive isotopes from one of four nuclear power plants in the affected area. This report, first in a series, considers events through March 17, as recorded at Fukushima Medical University (FMU), where the affiliated hospital became a center for emergency care. The author is an American transfusion medicine specialist in the Department of Blood Transfusion and Transplantation Immunology at FMU.

It seemed clever at the time. In early 2011, a conference advertisement promised a “Tsunami of Genome Science.” After March 11, the organizers re-branded their conference theme to “Revolution in Genome Science” and offered condolences to those affected by the magnitude 9.0 earthquake and tsunami that devastated Tohoku, the northeast region of Japan’s main island, Honshu. Doctors and scientists at Fukushima Medical University (FMU) encountered a second tsunami: a flood of health and welfare inquiries from colleagues around the world. To help respond to these inquiries, the author, a first-language English speaker, composed blocks of text that could be inserted into emails. This was the first step of an ongoing effort to provide international colleagues and the general public with reliable information from Fukushima.1

Health and welfare inquiries were often accompanied by offers of assistance. California Blood Bank Society (CBBS) website editor and board member Eileen Selogie was among the helpful correspondents. She and Jed Gorlin (Medical Director and Vice President of Memorial Blood Centers in Minnesota) further encouraged the author to document events for eventual publication. This article and those that follow are the fruit of their encouragement. As an interim measure to address immediate global interest in Japan’s disaster response, Ms. Selogie secured CBBS board approval in mid-March, 2011, to post narratives, photographs, and official announcements on the CBBS Today website, as events were unfolding.

The sections that follow begin with a retrospective of March 11 drafted some months later, followed by material prepared and posted online during the early disaster response period. A thoughtful reviewer wondered if the narratives should be arranged topically rather than in chronological order. Topical reporting has merit, and indeed, Japan’s disaster response experience should ultimately contribute to topically organized documents, such as the CBBS Disaster Response Plan.2  On the other hand, real disasters do not unfold one problem at a time. Japan was simultaneously confronted with earthquake and tsunami damage, followed almost immediately by a nuclear accident that spawned real and imagined perceptions of risk. The human response to all of these was, and is, complex. Jumping from one problem to another in real life is hard to simulate, but a chronologically organized report might convey some of the flavor of life, and work, during a multifaceted crisis.

For historical authenticity, the narratives are presented in their original form, including the use of first-person voice and literary styles not normally used in peer-reviewed scientific literature. Occasional edits have also been made for the sake of authenticity. For example, the original March 13 narrative mistakenly reported that FMU uses an average of 100 tons of water per day. The correct average, 150 tons, has been reported elsewhere.3,4

One hazard of the first-person voice and point of view is that a body of work might appear to be about its author. In fact, the real story herein concerns a diligent and resourceful people – the Japanese – from whom we all might learn something. The story begins.

A magnitude 7.2 earthquake on March 9 was merely a foreshock to the now-famous magnitude 9.0 event of Friday, March 11. I was working alone in a 5th floor office; next door, also working alone, was Alain Ngoma, a Congolese medical doctor just finishing his PhD in our department. Professor Hitoshi Ohto, our department chair and medical school dean, was more than 1000 kilometers away attending a conference.

The shaking on March 11 didn’t stop; it got worse. I stepped into the next office. “Alain-sensei, our Japanese colleagues seem to prefer the hallway when this happens.” We moved together into the hall. Pieces of sheetrock and ceiling tile were falling to the floor. A fire extinguisher spilled out of its retainer. A full-width steel barrier door, normally flush against the wall, swung loose into the hallway just a few meters from where Dr. Ngoma and I struggled to remain standing.

A somber aphorism of medicine came to mind: “Bleeding always stops.” Tremors, too. In either case, the goal is to maintain pulse and respiration. Breathe, pray, repeat. Foxholes and earthquakes have something in common.

Medical instincts, and middle age, come in handy when this sort of thing happens. I wasn’t inclined to worry about myself. But Alain, in his thirties, has a wife and two young children. Please, let them survive.

The shaking stopped. We opened our office doors. Full-length bookshelves in Japan are routinely secured to the wall and ceiling. They were fine, but things didn't turn out well for the books, or a laser printer I had unwisely placed atop a four-drawer filing cabinet next to my desk. Yes, we did well by stepping into the hall.5

Aftershocks continue. Our hospital is now receiving patients from outside the prefecture, for which reason one helipad isn't enough, and the students' soccer field is now a base for four more "Doctor Heli" air ambulance teams, and Self-Defense Force helicopters.

Fukushima City is not close to the eponymous nuclear plant, and we are inland from Sendai. No tsunami here, but no running water, either. Electricity OK and I could queue to fill some jugs from a water truck that came to the neighborhood. That took more than an hour, but this is Japan, and people passed the time in friendly, quiet conversation. The medical center itself normally uses around 150 tons of water per day. Reserves fell below 500 tons over the weekend. A water rationing protocol started; laboratory procedures are being modified as much as possible, and employees have been asked to use chemical toilets in the parking lot instead of our usual indoor plumbing.

An orderly queue for water. March 12, Fukushima City, Hourai Neighborhood, near Fukushima Medical University.	Homeward bound with 16 liters of potable water. March 12, Fukushima City, Hourai Neighborhood, near Fukushima Medical University.

Experience here in Fukushima and reports from Amateur Radio operators around Japan confirm that cell phone voice and messaging services are unreliable or completely inoperable during a disaster – even in a country that is accustomed to earthquakes and has world-class voice and data service.

On a bright note, people continue to exercise the good manners and cooperation that make living and working here worthwhile. As one person, I can't do much, but as part of a team, I'm trying to be useful.

My career has had some interesting turns, but life has been pretty soft, so this particular experience might come in handy sometime in the future. I took some on-the-scene pictures over the weekend, but of course there are limits because of patient privacy.

Being a specialist with an interest in disaster response is not quite the same as being a disaster specialist. Maybe my biggest contribution to the effort on Sunday was tracking down some bakery rolls, and then catching up with a surgeon who had been on overnight duty and still hadn't eaten by mid-afternoon.

Being human, he promptly inhaled two rolls. Being a surgeon, he washed them down with some strong coffee. Being Japanese, he put the rest away, for others, and went back to work.

Yesterday afternoon, I was among those in the lab from whom Dr. Takahiro Kanno got consent and drew screening samples, in case we have to donate blood, especially platelets, in the hospital. The Japanese Red Cross and its donors are able and willing, but contingency planning is essential when transportation infrastructure and access to petrol is compromised.

Fukushima Medical University is still outside the radiation evacuation area, but some incoming patients are being wanded with a Geiger counter, in much the same way as some people are wanded with a magnetometer at airport security.

Dr. Ohto mentioned that kelp is a source of iodine, and I had some in my freezer from a summer trip to the now devastated coast. So today I took a lunch of kelp and brown rice to work, but proper iodine tablets are also available. Of course it is sad to think that the person who harvested my radiation antidote was probably among those taken suddenly from this world.

Patients are the priority of our hospital cooking staff, so the employee cafeteria is only preparing and serving rice balls.

Fukushima City has electricity, but water lines are still being repaired. All in all, we're better off than the places appearing on TV. In short, I'm alive, well, doing what I enjoy doing, and maybe being of some help.

Yesterday I came to work with a headband headlight draped around my neck, to use as needed in dark hallways and staircases. We still have electricity, but are redoubling efforts to conserve. During the day, 9:00 am and 3:00 pm briefings were scheduled, for representatives of all departments. The afternoon briefing included a chart with background radiation measurements recorded on campus since 10:00 am March 13. There is a mild elevation compared with average natural background radiation, but accompanying examples show that a chest CT, and the barium Tilt-a-Whirl that I am offered every year for stomach cancer screening, each give more than a year's worth of natural radiation exposure in one test. Afternoon TV news showed other cities in the prefecture, like Koriyama, with higher levels than Fukushima City.

Overflow beds replace chairs in the hospital lobby. March 13, Fukushima Medical University.

Shortly after 7 pm Tuesday, another briefing was announced for 8 pm, at which we had a radiation specialist brief us on age-based risks, countermeasures, and Fukushima's nuclear reactor situation. Concern is highest for infants and children. There is an age-based protocol for iodine prophylaxis.

This morning's conference announced a "code red" protocol in case a significant amount of airborne radiation comes our way. Being, as I am, well over the magic age of 40, and also being from a cancer-resistant family, I am not particularly worried for my health. Judging from the concerned emails coming from overseas, I suspect that being outside Japan, trying to look in, would raise my cortisol levels. That's unhealthy, so I hope friends and colleagues reading this will try not to worry about me. I'm here for a reason.

Glad email is still intact. I found a note taped over the snail mail receptacle at our hospital's post office: closed, for want of gasoline. I think they are considering not only postal vehicles, but commuting employees. Our lab is operating on a skeleton crew, as employee gas tanks run low and public transportation is being cut back.

Fortunately, an envelope from Minnesota somehow got delivered, and it was waiting for me in the lab this morning. My sister Judy buys 100 g bars of Lindt 85% cocoa chocolate when they are on sale at Target or Cub. Same product is 2-3x more expensive at import shops here. Lindt bars are ballast in a monthly USPS Priority envelope otherwise containing forwarded mail. I opened the envelope and handed the chocolate to our lab staff. As always, the bounty will be slowly savored and shared by all in our break room. It might be especially welcome this time, as grocery stores are closed or have limited operating hours.

Making up for the hard realities of retail distribution, somehow rice balls are being made and delivered to hospital staff. These are better than what the name implies; they are generally decorated with one of the following: seaweed, thin strips of pickled vegetable, sesame seeds, or a salt-cured plum. At this morning's emergency preparedness conference, there was also some white bread for department reps to take back to their staffs. Typical for Japan, each "loaf" of white bread was 5 slices in a plastic wrapper. Lots of things here get wrapped in plastic, but households and communities are diligent about recycling. This and other good behaviors are holding up during the crisis.

This morning's news, and an email from the US Embassy, recommended, "as a precaution, that American citizens who live within 50 miles (80 kilometers) of the Fukushima Nuclear Power Plant evacuate the area or to take shelter indoors if safe evacuation is not practical." Yesterday, a telephone call from the embassy in Tokyo was less urgent. The embassy representative asked about my situation, whether I had been in touch with stateside family and friends, and if I needed any assistance. Back in February, 2009, a little over a year into my position at FMU, I registered online with the American Citizen Services Unit of the US Embassy in Tokyo. Since then, helpful emails have come at least once a month from the embassy, and more often in response to urgent situations.

The US Embassy says that its recommendation to evacuate or take shelter is consistent with Nuclear Regulatory Commission (NRC) guidelines that would apply to a similar situation in America. I accept this as prudent risk avoidance, and under slightly different circumstances would comply. In my particular case, I am at a medical university with round-the-clock radiation level measurements and a "code red" protocol in place.

Also in our department is an MD from Congo, who just finished a PhD concerning immune system reconstitution after bone marrow transplant. His government also wants its citizens to relocate to safer areas. Besides a wife, he has a toddler and an infant. Mainly for their sake, our staff found a three-bus itinerary to get him to Niigata, the closest city with bullet trains running. From Niigata they can get to the Congolese Embassy in Tokyo, or to friends in Osaka. Prof. Ohto brought the whole family to our city center this noon, on his way to an emergency meeting with prefectural authorities.

An attention-getting aspect of the March 11 retrospective is the earthquake itself. It created physical hazards for which the appropriate response was to move from offices to a hallway. Not so attention-getting, but absolutely essential, is the need to communicate emergency response behaviors across barriers of language and culture. Colleague Alain Ngoma understands this well, and was motivated to help FMU medical students produce a guidance document to help foreign residents of Japan cope with earthquakes.6  In the early days of our crisis, NHK, Japan’s public broadcaster, put advisories on the air in all of the most commonly used foreign languages.

Several points emerge from the March 13 narrative. FMU suddenly had to receive emergency patients from anywhere in the disaster area. The earthquake and tsunami rendered 118 medical facilities unusable in Iwate, Miyagi, and Fukushima prefectures.7 The influx of patients by air ambulance exceeded the capacity of FMU’s single helipad, so a soccer field had to be pressed into service. As the soccer field was on university property adjacent to the hospital, there were no administrative hurdles and logistical challenges were minimal. Other institutions might have more difficulty in similar circumstances, but pre-planning can be helpful. Gold Coast Hospital in Southport, Queensland, Australia conducts annual emergency exercises and has negotiated the use of a non-affiliated sports field to accommodate air ambulance helicopters (Quirine O’Loughlin, personal communication, 2011).

FMU sustained little physical damage, but lost municipal water and had to rely on reserve tanks on campus. Extreme conservation measures required the cooperation of staff, visitors, and to some degree, patients. For any resource, it is prudent to know how much is used, where it comes from, where else it can come from, and how to conserve. Government agencies and utilities maintain priority lists for restoration of services. Blood centers should take the initiative to be on these lists.8  A public relations benefit might also accrue to blood centers that are open about the volumes and costs of necessary utilities and services. Such information may allay suspicions about collecting money for a product that is donated for free.

One more point from March 13 is that normal communication channels were interrupted in two ways: (1) infrastructure damage in the disaster areas, and (2) overuse elsewhere. In any such situation, Amateur Radio remains a viable alternative, as discussed in the CBBS Disaster Response Plan and other publications.2,9,10

Another disaster response issue emerges in the brief March 14 narrative. Employees who remain on duty beyond normal hours eventually need to be nourished. Hospitals kitchens and dining facilities depend on an interruptible supply chain. Blood centers do not necessarily have food services other than their donor refreshment areas. Even if it is difficult to stockpile non-perishable food items, it would be prudent to maintain a generous inventory of bottled water. This was proven again and again in the wake of America’s 9-11, after which many blood centers had to consider the safety and comfort of people queuing to donate blood, often outdoors under a hot sun.

Japan’s 3-11, like America’s 9-11, saw an increase in volunteerism, including blood donors. Outside Japan’s disaster area, Red Cross blood centers could accommodate donors. Inside the disaster area, roads were damaged, gasoline was in short supply, and the earthquake had crippled a centralized testing facility in the city of Sendai. Fortunately, the Department of Blood Transfusion and Transplantation Immunology at FMU is equipped to collect autologous whole blood and research platelets, so we recruited, consented, and screened employees to be emergency donors, as described in the March 15 narrative and a previous CBBS Today article.11 Regrettably, Japan’s disaster was a mass casualty event rather than a mass trauma event, so FMU’s emergency donors were not needed.

Radiation from the crippled Fukushima Daiichi nuclear power plant emerges as a confounding factor in the March 15, 16, and 17 narratives. Expert articles are now available about radiation and health in an issue of the Fukushima Journal of Medical Science (open access through J-STAGE, the Japan Science and Technology Aggregator – Electronic, at http://www.jstage.jst.go.jp/browse/fms/57/2/_contents). 12-18

Ancillary to the issue of radiation is that various nations issued evacuation advisories to their citizens. In Japan, where very few health care providers are foreign nationals, these evacuation advisories did not have a significant impact on health care delivery, but anxiety about radiation, influenza, severe acute respiratory syndrome (SARS), etc. warrant contingency planning vis-à-vis potential patient volume, availability of healthcare workers, and, in the case of blood centers, donor volume and eligibility.

1. Nollet KE. Words to the world: radiating truth from Fukushima. Surgery Frontier, 2011; 18(4):45-47.
2. CBBS Disaster Response Plan. http://www.cbbsweb.org/links/disaster_plan.html
3. Nollet KE, Ohto H. Japan: standing firm on shaky ground. Transfusion and Apheresis Science, 2011; 44:327-329.
4. Abrams M, Nollet KE. A bird’s-eye view of Japan’s disaster aftermath. Mayo Alumni, Fall 2011; 8-13. http://www.mayo.edu/libraries/alumni_documents/mc4409-0811a.sflb.ashx
5. Nollet KE. Pacific reflections. Manuscript in preparation.
6. Tokumoto A, Gon C, Nagashima C, Ebihara K, Nakagawa M. To reduce foreigners’ anxiety. In Essays from Fukushima on the Great East Japan Earthquake. Yasumura S, Goto A, Ngoma A, editors. Fukushima University Press, 2011; Chapter 9:49-55.
7. Kyodo News. 118 medical facilities wrecked in disaster zone. Japan Times, 2011; April 26. http://www.japantimes.co.jp/text/nn20110426a6.html
8. Klinck B, Nollet KE. Relating the Japanese earthquake experience to blood center disaster planning. ABC Newsletter, 2012; 2:1-6.
9. Zuetell M. Amateur Radio support for hospitals. In Hospital preparation for bioterror. McIsaac JH, editor. Academic Press, 2006; Chapter 17:219-227.
10. Nollet KE. Shortwave radio? In the Internet age? Journal of Medical English Education, 2010; 9(2):89-93.
11. Nollet KE, Kitazawa J, Kanno T, Ohto H. SOP: standard operating procedure, or save our patient? CBBS Today – Journal of the California Blood Bank Society, 2012; 30(1). http://www.cbbstoday.org/archives/spring2012/art_casereport.php
12. Wada I, Ohto H. Fukushima Symposium: a brief note. Fukushima Journal of Medical Science, 2011; 57(2):69. https://www.jstage.jst.go.jp/article/fms/57/2/57_2_69/_article
13. Kobayashi K. Radiation measurements at the campus of Fukushima Medical University. Fukushima Journal of Medical Science, 2011; 57(2):70-74. https://www.jstage.jst.go.jp/article/fms/57/2/57_2_70/_article
14. Yamaguchi K and the Radiation Survey Team of Fukushima University. Investigations on radioactive substances released from the Fukushima Daiichi nuclear power plant. Fukushima Journal of Medical Science, 2011; 57(2):75-80. https://www.jstage.jst.go.jp/article/fms/57/2/57_2_75/_article
15. Takamura N, Yamashita S. Lessons from Chernobyl. Fukushima Journal of Medical Science, 2011; 57(2):81-85. https://www.jstage.jst.go.jp/article/fms/57/2/57_2_81/_article
16. Nollet KE. An American hibakusha in Fukushima. Fukushima Journal of Medical Science, 2011; 57(2):86-89. https://www.jstage.jst.go.jp/article/fms/57/2/57_2_86/_article
17. Sobue T. Scientific approach to radiation-induced cancer risk. Fukushima Journal of Medical Science, 2011; 57(2):90-92. https://www.jstage.jst.go.jp/article/fms/57/2/57_2_90/_article
18. Sekiya N. What is fuhyohigai?. Fukushima Journal of Medical Science, 2011; 57(2):93-99. https://www.jstage.jst.go.jp/article/fms/57/2/57_2_93/_article