Okumura and Tokuno ﻿Disaster and Mil Med (2015) 1:19
DOI 10.1186/s40696-015-0009-9

Open Access

CASE STUDY

Case study of medical evacuation
before and after the Fukushima Daiichi nuclear
power plant accident in the great east Japan
earthquake
Tetsu Okumura1* and Shinichi Tokuno2

Abstract
Introduction: In Japan, participants in the disaster-specific medical transportation system have received ongoingtraining since 2002, incorporating lessons learned from the Great Hanshin Earthquake. The Great East Japan Earthquake occurred on March 11, 2011, and the very first disaster-specific medical transport was performed. This article
reviews in detail the central government’s control and coordination of the disaster medical transportation process
following the Great East Japan Earthquake and the Fukushima Daiichi Nuclear Power Plant Accident.
Case description: In total, 124 patients were air transported under the coordination of the C5 team in the emergency response headquarter of the Japanese Government. C5 includes experts from the Cabinet Office, Cabinet
Secretariat, Fire Defense Agency, Ministry of Health, Labour and Welfare, and Ministry of Defense. In the 20–30 km
evacuation zone around the Fukushima Daiichi nuclear power plant, 509 bedridden patients were successfully evacuated without any fatalities during transportation.
Discussion and evaluation: Many lessons have been learned in disaster-specific medical transportation. The
national government, local government, police, and fire agencies have made significant progress in their mutual communication and collaboration.
Results: Fortunately, hospital evacuation from the 20–30 km area was successfully performed with the aid of local
emergency physicians and Disaster Medical Assistance Teams (DMATs) who have vast experience in patient transport
in the course of day-to-day activities. The emergency procedures that are required during crises are an extensionof basic daily procedures that are performed by emergency medical staff and first responders, such as fire fighters,
emergency medical technicians, or police officers. Medical facilities including nursing homes should have a plan for
long-distance (over 100 km) evacuation, and the plan should be routinely reevaluated with full-scale exercises. In
addition, hospital evacuation in disaster settings should be supervised by emergency physicians and be handled bydisaster specialists who are accustomed to patient transportation on a daily basis.
Keywords: Disaster, Medical transportation, Great East Japan earthquake, Government*Correspondence: feokumura@mac.com
1
Countermeasures against NBC (Nuclear, Biological, and Chemical)
Threats, Office of Assistant Chief Cabinet Secretary for National Security
and Crisis Management, Cabinet Secretariat, Government of Japan,
Nagatacho 2‑4‑12, Chiyoda, Tokyo 100‑0014, Japan
Full list of author information is available at the end of the article© 2015 Okumura and Tokuno. This article is distributed under the terms of the Creative Commons Attribution 4.0 International
License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any
medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commonslicense, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.
org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Okumura and Tokuno ﻿Disaster and Mil Med (2015) 1:19

Background
In Japan since 2002, participants in the disaster-specificmedical transportation system, which include staff oflocal hospitals, emergency department staff, emergency
medical technicians, police and fire fighters, are consistently trained in exercises for disaster-specific medical transportation. On March 11, 2011 at 14:46, theGreat East Japan Earthquake hit the northeastern partof mainland Japan. It was the most powerful earthquake
ever recorded to hit Japan, and the earthquake triggered powerful tsunami waves that reached heights up
to 40.5 m. The National Police Agency confirmed 15,891
dead, 6152 injured, and 2584 missing. When this earthquake occurred, the very first disaster-specific medicaltransport in Japan was initiated [1]. This article reviews,
in detail, the central government’s coordination of thedisaster medical transportation process following theGreat East Japan Earthquake and the Fukushima Daiichi
Nuclear Power Plant Accident, and includes the roles andactions of the central operation and the lessons learned
from this disaster. Shimada et al. reported on the hospital evacuation following the Fukushima nuclear accident
from the viewpoint of local emergency physicians [2]. In
this article, we present the government’s coordinatingrole from the viewpoint of central government administrative officers and lessons learned from the viewpoint ofgovernmental disaster management. Recommendations
for future efforts are discussed.
On the morning of January 17, 1995, the Great Hanshin (Osaka-Kobe) Earthquake resulted in 6308 deaths
and 35,000 injuries [3]. In Japan, before the Great Hanshin Earthquake, disaster medicine and the concept ofdisaster-specific medical transportation were not wellestablished. In fact, on the day of the Great Hanshin
Earthquake, only one trauma patient was transported byhelicopter from the devastated area to an outside hospital. In the first 3 days after the Great Hanshin Earthquake,
only nine patients were transported by helicopters. Many
critically injured patients were left in the devastated area
without appropriate trauma care, at least 500 deaths due
to trauma caused by this disaster were thought to bepreventable.
In 2000, the Doctor-Heli system was introduced [4].
The Doctor-Heli system comprises a helicopter that carries an emergency trauma physician and a nurse withemergency medical rescue equipment to the scene of adisaster. This prefecture- and government-funded helicopter system enables the medical team to begin emergency treatment on-site and during transport to a nearby
trauma care facility. By 2012, 30 of the 47 prefectures inJapan had introduced the Doctor-Heli system.
In 2002, the South Kanto area Great Earthquake tabletop exercise was performed. In this exercise coordinated

Page 2 of 8

by the Cabinet Office of the Government of Japan, themain theme was medical transportation during a disastersituation. The Cabinet Secretariat, Cabinet Office, Ministry of Health, Labour and Welfare (MHLW), Ministryof Defense, and other related ministries made concerted
and united efforts to communicate and collaborate toensure medical transportation for victims who sustained
injuries during an earthquake.
Systemization of medical transportation following adisaster started with the lessons learned from the Great
Hanshin Earthquake, in which many persons were diedwithout appropriate trauma care; a major contributing factor was that devastated hospitals were not able
to provide appropriate trauma care. With these lessons
learned, DMATs were introduced in 2004 throughout
Japan. Education and central coordination of DMATs areoverseen by the MHLW, and the operation and maintenance of DMATs are managed by each prefecture. Members of DMATs are emergency trauma physicians, nurses,
pharmacists, and clerks. Following a disaster, the main
purpose of the medical transportation system is to savethe lives of trauma patients and to provide support for
hospitals that are overwhelmed by casualties. For thispurpose, DMATs are first gathered at hubs outside thedisaster area (outer staging care units: outer SCUs) andthen transported to affected hospitals via hubs inside
the affected area (inner SCUs). Trauma patients are thentransported to the outer SCUs via the inner SCUs (Fig. 1).
Medical transportation inside the disaster area ismainly done by helicopters, including Doctor-Helisand ambulances, and outside the disaster area by fixedwing planes of the Self-Defense Forces. Critical patientsare accompanied by DMATs who continue to care forpatients during transport.
In 2004, at the time of the Niigata Chuetsu Earthquake,a Doctor-Heli was dispatched to the affected area; thiswas the very first disaster mission for the Japanese Doctor-Heli [5]. Since 2004, full-scale exercises of disasterspecific medical transportation are performed annually.
Year by year, participants are becoming more adept andproficient.
The Cabinet Office has created a manual of the governmental emergency response headquarter (ER-HQ).
According to this manual, ER-HQ is divided into three
A teams (Integration Teams), three B teams (Information Teams), eight C teams (Operation Teams), and five Dteams (General Affairs Team). The manual also describes
the teams and roles that are required during disastermanagement (see Table 1). Members of the C5 teamare from the Cabinet Office, Cabinet Secretariat, Fire
Defense Agency, MHLW, and Ministry of Defense. They
are tasked with the specialized coordination of disastermedical transportation. In 2007, the Cabinet Secretariat

Okumura and Tokuno ﻿Disaster and Mil Med (2015) 1:19

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Fig. 1 Initially, Disaster Medical Assistance Teams (DMATs) go from the outer staging care units to the inner staging care units. DMATs take patientsfrom the inner staging care units to the outer staging care units. Arrows show patient flow. JSDF Japan Self-Defense Forceadditionally invited an emergency physician to act as agovernment official and consultant.

Case description
Early stage before the Fukushima Daiichi accident: the firstchallenge

Within the Japanese government, the practical businessof disaster response is the responsibility of the Cabinet
Office. Immediately after the Great East Japan Earthquake happened, the governmental ER-HQ was set upby the Cabinet Office headed by the Prime Minister.
As planned, the C5 team was activated. The consulting emergency physician was dispatched by the Cabinet Secretariat to assist the C5 team. All members of
the C5 team were experts in the field of medical transportation. The initial task of the C5 team was to facilitate the establishment of inner SCUs and outer SCUs
(Fig. 2).
On the night of March 12, transportation of victims
to the outer SCUs had begun. Figure 3 shows the transportation flow. The Doctor-Heli system also played aremarkable role in medical transportation inside theaffected area. In total, 16 Doctor-Helis came from

unaffected areas and they treated and transported 149
critical patients [6, 7].
Disaster transportation was primarily handled by theprefectures. When local governments experienced difficulty in the coordination of disaster transportation, they
could ask the central government for help as needed.
Otherwise, the head office of DMATs or the MHLW
requested coordination of disaster transportation. The
C5 team received requests from any organization, including private sectors, and obtained as much informationas possible. In total, 124 victims were transported by air(Table 2). This number does not include the evacuationfrom the Fukushima Daiichi nuclear power plant accident. Among all the evacuees we coordinated, 19 weretrauma patients. In the Great East Japan Earthquake, themain cause of injuries was the tsunami; while many people died, survivors had few or relatively minor injuries
and few had serious trauma injuries. On the other hand,the earthquake and tsunami damaged the hospital in theaffected area and the demand for transport of patients on
dialysis and patients with neuro-degenerative diseases
who required artificial ventilation gradually increased
over time; 94 patients transported on March 23 wereOkumura and Tokuno ﻿Disaster and Mil Med (2015) 1:19

Table 1 Disaster management teams and tasks in the
ER-HQ of the Japanese Government
Group of teams

Team Tasks

A: Integration teams

A1

Integration of real-time situations

A2

Tactics building and analysis

A3

Meeting and public relations

B: Information teams B1

C: Operation teams

D: General affairs

Integration of information

B2

Information sharing

B3

Reporting of collected information

C1

Integration of operations

C2

Response

C3

Transportation

C4

Logistics

C5

Medical transportation

C6

Reception of international aid

C7

Sheltering and evacuation

C8

Infrastructure and life lines

D1

Integration of general affairs

D2

Distribution of food and nutritional supplements

D3

Publicity

D4

General affairs and communication

D5

Dispatch of government persons

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dialysis patients. The last case transported was a patient
who needed to return home (April 21 in Table 2).
Most of the patients included in the medical transportation scheme were treated in an unaffected area, recovered, and returned home using the usual transportation
system. One particular patient stabilized, but required
continuous treatment and could not return by surface
transport. The patient and his family wanted to go backto the hospital in their hometown and requested airtransport. Typically, return transportation cases are notincluded in the disaster transportation scheme; however,
MHLW and the Ministry of Defense negotiated and thepatient was finally transported by the Aero-Medical Evacuation Squadron (AMES) of the Japan Air Self-Defense
Force. The AMES is a so-called flying intensive care unit.
This case was the first for the AMES. The AMES uses
C130H transport aircrafts with Aero-Medical Evacuation
Units. The AMES may be used for medical evacuation in
future disaster settings.
During the height of the chaos, the requests for transportation contained confusing information, and duplicated information was often received. For example, aprefecture asked to transport 400 dialysis patients, so
ten buses were designated and prepared for this purpose.

Fig. 2 Inner staging care units and outer staging care units. The broad cross shows the outer staging care unit and the circle shows the inner staging
care unit. Dotted areas are the three main earthquake-affected prefectures: Iwate, Miyagi, and Fukushima prefectures

Okumura and Tokuno ﻿Disaster and Mil Med (2015) 1:19

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Fig. 3 Flow of patient air transportation. The earthquake affected Iwate, Miyagi, and Fukushima prefectures. DMAT Disaster Medical AssistanceTeam, HQ headquarters and AP airport

Table 2 Number of patients air-transported with the coordination of the C5 section
Plane and helicopterof the self-defense forces

Fire fighting
helicopters

March 110March 12
March 13

Daily account5
11

Cumulative
total value
0

5

5

11

16
19

March 143

3

March 15

2

2

21

0

21

March 160

21

March 18

March 174

4

25

March 194

4

29

March 2000March 2100March 22
March 23

94

0

0

94

123

March 2400March 25

0

0

1

124

Apr 211

Okumura and Tokuno ﻿Disaster and Mil Med (2015) 1:19

The same prefecture subsequently sent another request
for the C5 team to transport 400 patients on dialysis, so
the C5 team obtained an additional 10 buses, only to haveboth requests cancelled by the prefecture.
After the Fukushima Daiichi accident: the second challenge

The tsunami damaged the Fukushima nuclear power
plant, and day by day the situation at the power plant
deteriorated. The most tragic situation in the early stageof medical transportation was at Futaba Hospital. Futaba
Hospital (including Deauville Futaba, an adjunct nursing
home to Futaba Hospital) was within 5 km of the Fukushima Daiichi nuclear power plant accident and patientevacuation was required. During the chaos, Futaba Hospital lost three patients before the morning of March 14,
and a total of 50 patients by the end of March due to theinappropriate medical care circumstances [8]. In the process of the evacuation, Futaba Hospital patients were initially moved to a general evacuation center with healthy
citizens and subsequently moved to hospitals. Each of
the four hospitals in the 20-km zone should have had aconcrete evacuation plan and conducted drills as part ofa prefectural disaster plan, but in reality only one of these
hospitals had an evacuation plan.
Finally on March 15, the government decided to define
the evacuation zone as a 30-km circle around the nuclear
power plant. At that time, there were 1000 bedridden
patients in hospitals and nursing homes in the evacuation zone. These 1000 bedridden patients needed transport from the inner area to an outside area as soon as
possible. This was a difficult task and absolutely beyond
the capacity of the air transportation scheme. Meanwhile,the DMATs had started to withdraw out of Fukushima.
Originally, the activity period of the DMATs was definedas the first 72 h after the disaster. The C5 team requested
the DMATs to help with this task. In the early stage, realtime information on the medico-social situation of theevacuation zone was lacking; therefore, two members of
the C5 team including an emergency physician were dispatched to the Fukushima governmental headquarters(HQ) on March 17. The mission of the two C5 delegates
was to communicate, coordinate, and collaborate to savepatients, including the 1000 bedridden patients in the
20–30 km evacuation zone. When the C5 team members
reached the prefectural HQ, local government employees
were trying to match patients from inside SCUs to outside SCUs one case at a time. This excessive coordination proved to be labor-intensive and ineffective. Thus,
if the medical transportation team were to spend theirtime in this manner, they could never successfully evacuate a large number of patients. Therefore, the C5 delegation decided that the receiving prefecture must accept
the entire group of patients, knowing only the number ofPage 6 of 8

patients and distribution of injury severity. The delegation negotiated with the concerned organizations thatwere part of the coalition of the central C5 team. Surrounding prefectures came to terms with this dynamic
scheme under the strong leadership of the MHLW andfinally the transportation started to proceed smoothly.
Figure 4 shows this scheme.
In this scheme, bedridden patients were first collected
at the screening and triage area. In theory, patients who
had been in the hospital had no risk of radiation contamination. However, surrounding prefectures that had
not sustained damage from earthquakes, the tsunami,or the nuclear accident were concerned about radioactive contamination on patients. At the 30-km line, radiation screening and triage were established, and DMAT
and other teams checked the patients for contamination,
evaluated the physical status of patients, and performed
triage. According to the patients’ physical status, transportation measures (helicopters, ambulances, buses)
were selected. Patients who were unable to withstandlong-distance transportation were sent to the local central hospital, Fukushima Prefectural University Hospital.
As a result, 509 patients were successfully transported
from inside to outside of the evacuation zone without
any deaths occurring during transportation. Voluntary
non-governmental organizations were also engaged intransportation from the evacuation zone; unfortunately,
several deaths were reported during the transportation, presumably because of inexperience in medicaltransportation.
In Japan, the Fire and Disaster Management Agency
established a system to allow the central government torequest municipal fire brigades to form emergency rescue teams in the event of large-scale disasters such as
major earthquakes and accidents at nuclear power plants.
This scheme was also supported by unaffected local governments from all over Japan. Ambulances are not fuelefficient and require large quantities of gasoline. The
C5 team members, in close collaboration with the local
branch of the Ministry of Economy, Trade, and Industry,
were able to maintain sufficient quantities of gasoline.
The C5 team also coordinated the transportation of medical oxygen cylinders and special drugs such as methylene
blue, which were needed for the nuclear crisis.

Discussion and evaluation
Many lessons have been learned in disaster-specificmedical transportation. The national government, local
government, police, and fire agencies have made significant progress in their mutual communication andcollaboration.
Fortunately, hospital evacuation from the 20–30 km
area was successfully performed with the aid of local

Okumura and Tokuno ﻿Disaster and Mil Med (2015) 1:19

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Fig. 4 Evacuation scheme in the Fukushima nuclear evacuation

Table 3 Recommendations for future disaster medical transportation
Recommendations
1. Plan for long-distance evacuation

Medical facilities, including nursing homes, should have a plan for longdistance disaster-specific (over 100 km) evacuation. This plan should bepracticed with full-scale exercises and when flaws are found, they shouldbe evaluated and eliminated

2. Securement of transportation measures and designated hospitals

A disaster-specific evacuation plan should include the securement oftransportation measures and designated hospitals where patients canbe sent

3. Multiple communication measures

Healthcare facilities should have two or three independent communication measures such as a radio, satellite phone, amateur radio, and multichannel access radio systems

4. Supervision by emergency physicians and disaster specialists

Hospital evacuation in disaster settings should be supervised by emergency physicians and be handled by disaster specialists who are accustomed to patient transportation on a daily basis

5. Dispatch of central governmental persons to the disaster site

Selected members of the central government should not stay in thecentral office waiting for information from the disaster site, but should
go into the disaster site, get precise information, and make use of theinformation to formulate a governmental response

6. The presence of an emergency physician or disaster researcher in thecentral government

The presence and availability of an emergency physician or disaster
researcher in the central government can greatly contribute to the governmental response, especially for disaster-specific medical transportation

Okumura and Tokuno ﻿Disaster and Mil Med (2015) 1:19

emergency physicians and DMATs who have vast experience in patient transport in the course of day-to-day
activities. Voluntary non-governmental organizations
were also engaged in transportation with good intentions, but they lacked experience. Tasks, activities, or
behaviors that are not performed on a routine basis
cannot be readily performed during an emergency. The
emergency procedures that are required during crises are
an extension of basic daily procedures that are performedby emergency medical staff and first responders, such as
fire fighters, emergency medical technicians, or police
officers.

Results
The principals in disaster response are the local governments. One of the most important roles of central government personnel is to resolve impediments faced by
the local government. To identify these impediments,
dispatch of central government employees was extremely
useful. The delegation of the C5 section was dispatched to
Fukushima for collecting precise medico-social information; this became the catalyst for responding to the crisis.
The central government could then evaluate whether the
local response system was working smoothly and whensomething was less than optimal the central government
could step in and offer assistance. Recommendations
for future medical transportation from lessons learned
following the Fukushima nuclear accident are shown in
Table 3.
Footnote
This article presents the authors’ personal opinions
as emergency physicians/disaster researchers and is
not intended to be the official position of the Japanese
government.
Abbreviations
AMES: Aero-Medical Evacuation Squadron; AP: airport; C5: command, control,
communications, computers, and counter-intelligence; DMAT: Disaster
Medical Assistance Team; ER-HQ: Emergency Response Headquarter; HQ:
headquarters; MHLW: Ministry of Health, Labour and Welfare; SCU: Staging
Care Unit; AMES: Aero Medical Evacuation Squadron; JSDF: Japan Self-Defense
Force.
Authors’ contributions
To engaged in the whole scheme and application of disaster specific medicaltransportation, and described the design and implementation. ST participatedin the article design and coordination and helped to draft the manuscript.
Both authors read and approved the final manuscript.
Author details
1
Countermeasures against NBC (Nuclear, Biological, and Chemical) Threats,
Office of Assistant Chief Cabinet Secretary for National Security and Crisis
Management, Cabinet Secretariat, Government of Japan, Nagatacho 2‑4‑12,
Chiyoda, Tokyo 100‑0014, Japan. 2 Verbal Analysis of Pathophysiology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.

Page 8 of 8

Acknowledgements
The authors gratefully acknowledge all members of the emergency response
headquarters of the Japanese government, local governments, DMATs, andconcerned organizations. The authors dedicate this work to the victims andtheir families in the Great East Japan Earthquake and the Fukushima Daiichi
Nuclear Power Plant Accident.
Competing interests
The authors declare that they have no competing interests.
Received: 8 January 2015 Accepted: 25 August 2015

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