SPECIAL REPORTLessons Learned from the Aeromedical Disaster
Relief Activities Following the Great East JapanEarthquake
Hisashi Matsumoto, MD, PhD;1 Tomokazu Motomura, MD;1 Yoshiaki Hara, MD;1Yukiko Masuda, MD;1 Kunihiro Mashiko, MD, PhD;1 Hiroyuki Yokota, MD, PhD;2Yuichi Koido, MD, PhD3

Abbreviations:
DMAT: Disaster Medical Assistance TeamHEMS: helicopter emergency medical service
MHLW: Ministry of Health, Labour andWelfare
SDF: Self Defense Force

Abstract
Introduction: Since 2001, a Japanese national project has developed a helicopter
emergency medical service (HEMS) system (‘‘doctor-helicopter’’) and a central Disaster
Medical Assistance Team (DMAT) composed of mobile and trained medical teams for
rapid deployment during the response phase of a disaster.
Problem: In Japan, the DMAT Research Group has focused on command and control of
doctor-helicopters in future disasters. The objective of this study was to investigate theeffectiveness of such planning, as well as the problems encountered in deploying thedoctor-helicopter ﬂeet with DMAT members following the March 11, 2011 Great East
Japan Earthquake.
Methods: This study was undertaken to examine the effectiveness of aeromedical disaster
relief activities following the Great East Japan Earthquake and to evaluate the assemblyand operations of 15 doctor-helicopter teams dispatched for patient evacuation withmedical support.
Results: Fifteen DMATs from across Japan were deployed from March 11th throughMarch 13th to work out of two doctor-helicopter base hospitals. The dispatch center at
each base hospital directed its own doctor-helicopter ﬂeet under the command of DMAT
headquarters to transport seriously injured or ill patients out of hospitals located in thedisaster area. Disaster Medical Assistance Teams transported 149 patients using thedoctor-helicopters during the ﬁrst ﬁve days after the earthquake. The experiences andproblems encountered point to the need for DMATs to maintain direct control over1) communication between DMAT headquarters and dispatch centers; 2) information
management concerning patient transportation; and 3) operation of the doctor-helicopter
ﬂeet during relief activities. As there is no rule of prioritization for doctor-helicopters torefuel ahead of other rotorcraft, many doctor-helicopters had to wait in line to refuel.
Conclusion: The ‘‘doctor-helicopter ﬂeet’’ concept was vital to Japan’s disaster medical
assistance and rescue activities. The smooth and immediate dispatch of the doctorhelicopter ﬂeet must occur under the direct control of the DMAT, independent fromlocal government authority. Such a command and control system for dispatching thedoctor-helicopter ﬂeet is strongly recommended, and collaboration with local government
authorities concerning refueling priority should be addressed.

Received: August 10, 2011
Accepted: October 18, 2011
Revised: October 27, 2011

Matsumoto H, Motomura T, Hara Y, Masuda Y, Mashiko K, Yokota H, Koido Y.
Lessons learned from the aeromedical disaster relief activities during the Great East
Japan Earthquake. Prehosp Disaster Med. 2013;28(2):166-169.

1. Shock and Trauma Center, Chiba
Hokusoh Hospital, Nippon Medical
School, Chiba, Japan
2. Department of Emergency and Critical
Care Medicine, Nippon Medical School,Tokyo, Japan
3. National Hospital Organization Disaster
Medical Center, Tokyo, Japan
Correspondence:
Hisashi Matsumoto, MD, PhD
Hokusoh HEMS/Shock and Trauma
CenterChiba Hokusoh Hospital
Nippon Medical School
1715, Kamakari, Inzai, Chiba Pref.,270-1964, Japan
E-mail: hmatsu@nms.ac.jp
Keywords: Disaster Medical Assistance Team;disaster medical relief; doctor-helicopter;
Emergency Medical Service; Great East Japan
Earthquake; helicopter

Online publication: January 22, 2013
doi:10.1017/S1049023X12001835

Prehospital and Disaster Medicine

Introduction
As a national project under the direction of the Japanese Ministry of Health, Labour andWelfare (MHLW) to establish a Japanese emergency medical service (EMS) system,a helicopter EMS (HEMS) system—the so-called ‘‘doctor-helicopter’’ system—has beendeveloped and modeled on the ADAC in Germany, the REGA in Switzerland, and theLondon HEMS in the UK.1 Since 2001, the HEMS system has been established at
40 bases across Japan. At the end of ﬁscal year 2012, however, less than half the coverage
needed has been achieved. The HEMS system was established alongside that of a central

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Matsumoto, Motomura, Hara, et al

Disaster Medical Assistance Team (DMAT) composed ofmobile and trained medical teams that can be rapidly deployedduring the acute phase (within 48 hours) of a disaster.
Japan has one of the highest occurrences of earthquakes in theworld, and ranks second in the world for the number ofrotorcraft, but the utilization of helicopters in disaster situations is
not as advanced. Since 2003, the DMAT Research Group has
investigated the utilization and command of a ‘‘doctor-helicopter
ﬂeet’’ in major disasters.
This report examines the effectiveness of aeromedical disaster
relief activities and presents an evaluation of assembly andoperations of 15 doctor-helicopter teams that were dispatched forpatient evacuation with medical support following the Great East
Japan Earthquake. The experiences and problems encounteredoffer information for establishing nationwide aeromedical disaster
relief systems that can respond effectively to major emergencies ordisaster situations.
Aeromedical Disaster Relief Activities Undertaken
A magnitude 9.0 earthquake on March 11, 2011 off the Paciﬁccoast of the Tohoku region of Japan caused widespread damage.
The quake, one of the largest in recorded history, triggered atsunami up to 30 meters high along parts of the country’s eastern
coastline. The tsunami swept away everything in its path, including
houses, cars, and farm buildings, some of which were on ﬁre.
From March 11th through March 22nd, approximately
340 DMATs were assembled in the affected areas of Iwate,
Miyagi, Fukushima, and Ibaraki Prefectures, and from March 11th
through March 13th, in the acute phase of the disaster,
15 DMATs were deployed to work out of two doctor-helicopter
base hospitals at Fukushima Medical College Hospital andHanamaki Airport (Figure 1). Dispatch centers for the doctorhelicopter ﬂeet were established at the Fukushima and Hanamaki
sites on March 12th. Doctor-helicopter teams were dispatchedfor the transport of patients with medical support from thedisaster area either to hospitals outside the area or to a staging
care unit for later wide-area transportation. The base atHanamaki directed seven doctor-helicopter teams and transported a total of 39 patients from hospitals on the coast (mainlyin Iwate Prefecture) that were damaged by the tsunami to sites
outside the affected area. Each of the eight doctor-helicopter
teams stationed at the Fukushima base transported a total of
22 patients from hospitals located on the coast of Miyagi andFukushima Prefectures.
On March 13th, a serious problem was identiﬁed inIshinomaki City on the coast of Miyagi Prefecture. Approximately
120 patients and 130 staff had been stranded at the severely
damaged Ishinomaki Municipal Hospital, which had not beenable to function as a hospital following the tsunami (Figure 2).
Their escape route was blocked as the city was submerged, and they
could not issue an SOS as there was no electricity supply withall generators and redundant communications such as satellite
telephones damaged.
Early on the morning of March 14th, the advance headquarters of the DMAT based in the Miyagi Prefectural Ofﬁce
ordered that the patients in Ishinomaki Municipal Hospital beevacuated. All DMATs standing by at the Fukushima base weredispatched in ﬁve doctor-helicopters to execute the orders. Three
DMATs worked in Ishinomaki Municipal Hospital to prepare
the patients for evacuation and to transport the patients by
doctor-helicopters to the nearby Ishinomaki athletics ﬁeld, whereApril 2013

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Matsumoto & 2013 Prehospital and Disaster Medicine

Figure 1. Fifteen DMATs operating the doctor-helicopter
were assembled at Fukushima Medical College Hospitaland Hanamaki Airport.

Matsumoto & 2013 Prehospital and Disaster Medicine

Figure 2. The tsunami destroyed the ﬁrst and second ﬂoorof Ishinomaki Municipal Hospital.
two DMATs were stationed to receive the patients. From there
the Self Defense Force (SDF) transported the patients by
Chinook to Kasuminome Camp at Sendai and then onwards to aplace of safety. In addition, two doctor-helicopters from Hanamaki
base provided support on the afternoon of March 14th.
The operation started at 9:40 AM. However, it was temporarilysuspended in the morning because of a precautionary warningof another tsunami following an aftershock before being restarted
at 1:00 PM after the tsunami alert was lifted. The seven doctorhelicopter teams then worked to transfer patients from thehospital to the athletics ﬁeld, while taking water, food andgenerators to the hospital. A total of 86 patients were evacuatedby the doctor-helicopter teams during the daytime, with theremaining patients evacuated during the night of March 14th,and hospital staff evacuated the following day by SDF
helicopters. Altogether, 148 patients were evacuated by theDMATs using 15 doctor-helicopters over a ﬁve-day period
following the earthquake (Table 1). The doctor-helicopter teams
completed their mission to transport patients with medical
support by March 15th.
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HEMS Following the Great East Japan Earthquake

Doctor-Helicopter
Teams Deployed

Details of Transport

No. of Transports
Within thedisaster area

To outside thedisaster area

Hokkaido (North)

1010

Aomori

22

Fukushima

55Gunma1313

Saitama66

Chiba (North)

3027

Nagano11Shizuoka (West)

18

18

Aichi

66

Gifu

44Osaka

20

17

3

Hyogo

514

Yamaguchi

1818

Kochi

33

Fukuoka

77148

138

Total

Ishinomaki Municipal
Hospital
23327

16171671088Matsumoto & 2013 Prehospital and Disaster Medicine

Table 1. Transportation by DMAT Using Doctor-Helicopters
Abbreviation: DMAT, Disaster Medical Assistance TeamDiscussion
Sixteen years ago, Japan was rocked by an earthquake in theHansin-Awaji area. The number of fatalities was .6,000 and thenumber of ‘‘preventable deaths’’ has been estimated at .500.2
This experience highlighted the need for medical services andtransportation of injured and sick persons to be provided in adisaster area. Within the ﬁrst 24 hours after the Hansin-Awaji
Earthquake, an estimated 380 people needed to be airlifted
outside of the affected areas so they could receive emergency
medical treatment; a further 120 casualties needed to betransported by air over the next 48 hours. On the day of theearthquake, however, only one patient was transported byhelicopter and only 17 within the ﬁrst 72 hours. The MHLW
recognized from this event that even with the large number ofhelicopters in the country, they were not available to use indisaster situations unless they were already being utilized inhandling daily emergencies.
Against this backdrop, the MHLW formulated two policies.
One of these policies involved the Japanese government
establishing a disaster medical system that deployed DMATs.3
The Japanese DMAT consists of teams of doctors and nurses
who provide medical support and administrative staff to handle
the logistics, and they rapidly deploy in the acute phase of adisaster (within 48 hours). Disaster Medical Assistance Teams
focus on providing medical care and relief activities to save thePrehospital and Disaster Medicine

lives of severely-injured or ill casualties. Their most importantrole is to assist hospitals in the affected areas to receive casualties,
for example, by providing triage, treatment, emergency care, andtransportation by land and air. In the case of a large-scale disastercovering a widely damaged area, DMATs can be deployed toprovide aeromedical disaster relief. As of May 2011, 430 medical
facilities, 813 teams, and 5,094 individuals had been trained.
The second policy involved developing a government-funded
HEMS system. The doctor-helicopter system has been operating
since 2001 and provides ‘‘onsite emergency department capability,’’ such as advanced prehospital treatment by emergency
physicians at the scene. It is now part of the established EMS
system in daily use in Japan. Since 2003, the DMAT ResearchGroup which is funded by a MHLW Health and Labour
Sciences Research Grant has been investigating the utilization ofdoctor-helicopters in major disasters. They have worked under
the assumption that rotorcraft from various organizations such as
the police, ﬁre department, and SDF will not be readily available
for aeromedical transportation during disaster relief activities
because these helicopters are not under direct control of theMHLW and are not for exclusive EMS use.
Although not all DMAT teams received advanced training fordoctor-helicopters, it is a general rule that medical crews who aredeployed to a disaster site, including the evacuation teams
discussed in this report, work as doctor-helicopter staff in dailyVol. 28, No. 2

Matsumoto, Motomura, Hara, et al

HEMS activity. The ﬁrst deployment of a doctor-helicopter by
the DMAT for aeromedical disaster relief was in 2007 following
the Niigata Chuetsu Off-Coast Earthquake. After the Iwate
Miyagi Inland Earthquake in 2008, two doctor-helicopters withDMAT members onboard were deployed in the disaster area.
From these deployments, the DMAT research group estimatedthat greater numbers of doctor-helicopters should assemble ateach of the base hospital site in future disasters, forming a‘‘doctor-helicopter ﬂeet.’’ The Research Group identiﬁed command and control of this ﬂeet as an issue requiring further study.
Some important points were learned from the experiences
following the recent Great East Japan Earthquake. First, theoperations in Tohoku have made clear the vital role that doctorhelicopter teams play in disaster medical assistance and rescue
activities. But, not all types of helicopters are suitable foraeromedical activities. It was clear that the ‘‘doctor-helicopter
ﬂeet’’ concept is superior to uncoordinated operations by eachdoctor-helicopter team; however, it is necessary to establish thelegal grounds for the use of doctor-helicopters in a disaster, as
there are no national rules regarding their deployment.
Second, there were many helicopters from various organizations present at the disaster sites which could not be used by
DMATs for medical transportation without separate adjustments
being made to the activities of these organizations, which would
ultimately delay operations. The operations of the doctorhelicopter ﬂeet ran smoothly because DMATs could be dispatched
immediately whenever DMAT headquarters requested because theindividual dispatch centers for the doctor-helicopter ﬂeet weredirectly controlled by DMAT headquarters, unlike the rotorcraft ofother organizations that are controlled by local government. Given
this foresight, a DMAT could complete its mission as originallyplanned by the Research Group.
There were some futile operations because information about
the patients needing transport was not centralized sufﬁciently.
To maintain direct control over communication between DMAT
headquarters and dispatch centers at the Fukushima andReferences
1. Matsumoto H, Mashiko K, Hara Y, et al. Effectiveness of a ‘‘doctor-helicopter’’ system
in Japan. IMAJ. 2006;8:8-11.
2. Ukai T. The Great Hanshin-Awaji Earthquake and the problems with emergency
medical care. Ren Fail. 1997;19:633-645.
3. Kondo H, Koido Y, Morino K, et al. Establishing disaster medical assistance teams inJapan. Prehosp Disaster Med. 2009;24:556-564.

April 2013169

Hanamaki sites, it was indispensable to establish information
management concerning patient transportation. Such a commandand control system for dispatching the doctor-helicopter ﬂeet isstrongly recommended.
As the third point, there is no rule of prioritization for doctorhelicopters to refuel ahead of other helicopters, such as those usedby the press. This resulted in many doctor-helicopters having to
wait in line to refuel. Collaboration with local government
authorities concerning a refueling priority should be addressed.
This was a strong recommendation following the event.
The literature contains of reports describing aeromedical
evacuation activities after a catastrophic earthquake4,5. HEMS
systems are an integral part of disaster relief measures undertaken
and a clear understanding of the medical capabilities of DMATs
in the aeromedical environment will help patients be evacuated ina safe and proper manner. The experiences and problems
encountered following the March 2011 disaster clearly point to
the need for DMAT to maintain direct control over communication between DMAT headquarters and the dispatch centers,
information management concerning patient transportation, andoperation of the doctor-helicopter ﬂeet during the relief activities.
Such information provides valuable information for establishingnationwide HEMS systems that can respond to major emergencies or disaster situations.
Conclusion
Although there had been few concrete plans laid down in Japanfor aeromedical evacuation activities in the event of a majordisaster and despite the fact that the many helicopters in thecountry remain largely unavailable for use by medical relief teams,
the two policies of the MHLW that established the DMATs andthe doctor-helicopter ﬂeet proved successful for patient evacuation
with medical support following the Great East Japan Earthquake.
Moreover, it is apparent that the smooth and immediate dispatch ofthe doctor-helicopter ﬂeet must occur under the direct control ofDMAT, independent from local government authority.
4. Martchenke J, Lynch T, Pointer J, et al. Aeromedical helicopter use following the1989 Loma Prieta earthquake. Aviat Space Environ Med. 1995;66:359-363.
5. Nia MS, Naﬁssi N, Moharamzad Y. Survey of Bam earthquake survivors’ opinions on
medical and health systems services. Prehosp Disaster Med. 2008;23:263-268.

Prehospital and Disaster Medicine