Many dentists participated in disaster victim identification (DVI) after the Great East Japan Earthquake and Tsunami in 2011. However, various problems were encountered due to the poorly organized dental identification system, and consequently, only 7.6% of all successfully identified cases were based on dental information. Japan has experienced several disasters, including the crashes of Japan Airlines Flight 123 and China Airlines Flight 140 and the 1995 Southern Hyogo Prefecture Earthquake, and after each of them, the need to improve the dental identification system was pointed out. Nonetheless, the lack of a well-organized system predictably resulted in confusion after the 2011 earthquake. This study compared and reexamined problems in dental identification after the above disasters to identify underlying factors and to discuss needed improvements related to DVI. It was revealed that the disasters preceding the 2011 earthquake had many points in common, and similar problems were repeatedly identified in DVI after the 2011 earthquake. The number of unidentified corpses even under ordinary conditions is greater in Japan. In addition, the success rate of dental identification after disasters is markedly lower in Japan than in countries that have established a death investigation and identification system. Urgent measures to reduce the number of unidentified corpses need to be implemented reflecting the outcomes of a review of past experiences.

【Objective】

During a disaster scenario where medical resources are scarce, the pressure infusion technique is a viable option to achieve fluid resuscitation. The technique requires rapid and maintenance modes of adaptation; however, only a limited body of scientific literature exists on the subject. In the present study we sought to determine the maximum and average drip rates achieved via applied buttocks pressure for rapid infusion and whether head pressure is adequate in achieving maintenance fluid resuscitation.

【Methods·Results】

(Examination 1: Investigating changes in drip rate under applied buttocks pressure)

We attached a 20 G peripheral catheter to adult and pediatric infusion sets and had a 65 kg subject apply pressure to the fluid bag via direct placement under the buttocks. Full content drip could not be achieved, however, the average drip rates for adult and pediatric infusion sets were 75 and 55%, respectively, of the maximum drip rates achieved five minutes after the drip was started.

(Examination 2: Investigating rapid infusion rate)

Adult infusion sets were used to examine four methods of infusion and pressurization: gravity infusion, 40 kPa pressure bag and placement under buttocks of 55 and 65 kg subjects. Adult infusion sets were used together with 18, 20 and 22 G peripheral catheters and maximum drip rates achieved one minute after initiating drip was measured. The lowest maximum drip rate was 12.8 ml/min which translates to 768 ml/hr.

(Examination 3: Investigating maintenance infusion rate)

Pediatric infusion sets were used to examine two modes of pressurization—infusion bags used together with 20, 22 and 24 G peripheral catheters were placed under the heads of 55 and 65 kg subjects. The maximum drip rates achieved one minute after initiating drip was measured. The drip rates were 2.2–3.4 ml/min and 1.0–1.1 ml/min for the 55 kg and 65 kg subjects, respectively. The correlation between subject weight and catheter gauge was poor.

【Discussion】

Although the results vary in response to materials available and subjects’ body weight, the rapid infusion technique achieved a minimum drip rate of 768 ml/hr. While utilization of subjects’ heads for fluid management as a standalone method is problematic, when used in combination from a total fluid management perspective, the maintenance infusion method could be adopted as supplemental strategy.

A traffic accident involving nine victims occurred at the entrance of a funeral hall, and three physicians were dispatched with a rapid response car for transporting medical personnel due to the multi-casualty incident. One physician rode in the ambulance with the victim with a red triage tag, ensured the victim’s venous access, and performed infusions and focused assessment with sonography for trauma (FAST) in the vehicle. The other two physicians performed secondary triage of eight victims with yellow and green triage tags according to the physiological and anatomical triage (PAT) method, selected the destination hospital, and determined the order of transport. After secondary triage at the scene, one victim was tagged red, four yellow, and four green; all were transported to their respective destination hospitals. On the day after the accident, one victim, who was tagged yellow and transported to another hospital, was transferred to our hospital with the diagnosis of bilateral hemothorax. Later, we verified the secondary triage of all victims, including those who were treated at other hospitals. With secondary triage at the scene, victims were appropriately categorized; however, we had not been able to identify chest injuries in two victims. To improve the precision of triage with the PAT method, it is important to perform medical examinations in an environment where the privacy of the victims can be ensured and to take note of life-threatening chest injuries such as hemothorax using portable sonography.

As Japan is a disaster-prone country, the people of Japan have long suffered from a variety of natural disasters, such as earthquakes, tsunamis, typhoons, landslides, floods, and volcanic eruptions, etc. So far, as the author (Piyatida Kalayanamitra [hereinafter referred to as “PK”]) has observed, in comparison with the people of Thailand, the people of Japan tend to be quite earnest in preparing for disasters so as to mitigate damage. However, the people of Thailand have also suffered from a variety of natural disasters, but despite that, they tend to ignore the risk. Therefore, it can be observed that the general attitudes toward natural disasters are different between Japan and Thailand. In order to analyze this difference, PK has collected disaster-related information by visiting once-devastated areas, interviewing disaster specialists of different backgrounds and a few laypersons, and holding discussions. The severe natural disasters of Japan are mostly unpredictable; however, on the other hand, the major natural disasters of Thailand often involve flooding and droughts, which come with a slow onset that allows people to have enough time to think about what to do and to evacuate before the worst-case scenario occurs. This is the reason for Thailand’s regular lower death toll despite great socio-economical damage. In Japan, people tend to keep the dark lessons of history fresh in mind, aided in recollection via literary records, pictures, photographs, statues, monuments, stories passed down, and other various ways. Therefore, knowledge of disasters in Japan is shared publicly and is transmitted from generation to generation. This attitude is not limited to specific regions or to some societal subgroups but is done as a whole, nationwide. In other words, the attitude of the people of Japan toward natural disasters is more ritualistic and is an important part of Japanese culture itself. As a tentative conclusion, Japan seems to have a more-matured sense of response regarding natural disasters based on common knowledge obtained from historical accounts. In addition, it is possible to attribute this to the high level of racial homogeneity in Japanese society, standardized language education (with a very high literacy rate as a result), and widespread information networks, including radio, television, telephones, newspapers, and the internet, etc.

In September 2015, our hospital’s disaster medical assistance team (DMAT) was deployed for the first time to a disaster area in Ibaraki Prefecture, Japan to assist for two days after flooding by the Kanto-Tohoku heavy rainfall.

After our DMAT was formed, we created a DMAT operations manual that included a section on backup logistical support. During this deployment, we encountered some problems in this manual involving communication methods, arrangements for maintaining regular contact with the DMAT, finding replacements to perform the duties of deployed DMAT members, and maintaining equipment. We revised the manual after the deployment. We began to use LINE™, an application which recently became popular, as a communications tool.

After this deployment, we introduced training on how to perform backup support as a base hospital along with DMAT training. We revised the manual regularly throughout training.

In conclusion, backup logistical support is necessary to reduce the burden on active DMAT members. Having a DMAT operations manual that includes backup logistical support and training of backup members is important when providing backup for a deployed DMAT.

Although it is a huge psychological burden for municipal employees to engage in mortuary operations, at the time of the Great East Japan Earthquake, courteous treatment of the bodies and sympathetic consideration by them for the bereaved families had a significant influence on the psychological recovery of the families. In mortuary operations the municipal employees have an important roles for taking care of the bereaved families. Keen awareness of their duties, being proud of their mission and achievement of comprehensive services to the families are supposed to be crucial factors that contribute to mitigating municipal employees’ psychological burdens and maintaining mental health of themselves. If they could prepare psychologically for the mortuary operations with adequate training programs in advance, it can be expected that further improvement in the quality of services to the families. The DMORT (Disaster Mortuary Operational Response Team) training program of Yokohama has a curriculum that covers almost all of these factors. The questionnaire after the training shows the participants understood enough about the significance of mortuary operations and mental attitude. Thus, the DMORT training program can contribute that the dedication to the missions results in municipal employees’ mental stability and is effective to avert their traumatic stresses under disastrous situations.