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Abstract. The Tokyo subway sarin attack was the second documented incident of nerve gas poisoning in Japan. Prior to the Tokyo subway sarin attack, there had never been such a large-scale disaster caused by nerve gas in peacetime history. This article provides details related to how the community emergency medical services (EMS) system responded from the viewpoint of disaster management, the problems encountered, and how they were addressed. The authors' assessment was that if EMTs, under Japanese law, had been allowed to maintain an airway with a n endotracheal tube or use a laryngeal mask airway without physician oversight, more patients might have been saved during this chemical exposure disaster. Given current legal restrictions, advanced airway control at the scene will require that doctors become more actively involved in out-of-hospital treatment. Other recommendations are: 1) that integration and cooperation of concerned organizations be established through disaster drills; 2) that poison information centers act as regional mediators of all toxicologic information; 3) that a reaI-time, multidirectional communication system be established; 4) that multiple channels of communication be available for disaster care; 5) that public organizations have access to mobile decontamination facilities; and 6) that respiratory protection and chemical-resistant suits with gloves and boots be available for out-of-hospital providers during chemical disasters. HE TOKYO subway sarin attack was the sec-T ond documented incident of nerve gas poisoning in Japan. The first mass public exposure t o sarin (methyl phosphonofluoridic acid l-methylethyl ester) gas occurred in the city of Matsumoto in June 1994.' From a worldwide historical perspective, the Tokyo subway sarin attack represents the largest disaster caused by nerve gas in peacetime history. Until these episodes, a terrorist attack with chemical warfare agents in a public setting was incomprehensible. Indeed, the Japanese believed that the Tokyo subway system was the safest transportation system in the world. As a result of this attack, many problems were encountered and the Japanese have been forced to radically alter their approach to disaster management.We previously published a preliminary report on the Tokyo subway sarin attack.2 The current article provides further detail related to how the community emergency medical services (EMS) system responded from the viewpoint of disaster management, the problems encountered, and how they were addressed. Companion articles address the hospital response3 and the national and international responses4 related to this event. NATIONAL AND REGIONAL EMS SYSTEMIn Japan, disaster planning is based on the "fundamental law of disaster management." This law

Abstract. The Tokyo subway sarin attack was the second documented incident of nerve gas poisoning in Japan. The authors report how St. Luke's Hospital dealt with this disaster from the viewpoint of disaster management. Recommendations derived from the experience include the following: Each hospital in Japan should prepare an emergent decontamination area and have available chemical-resistant suits and masks. Ventilation in the ED and main treatment areas should be well planned at the time a hospital is designed. Hospital disaster planning must include guidance in mass casualties, an emergency staff callup system, and a n efficient emergency medical chart system. Hospitals should establish a n information network during routine practice so that it can be called upon at the time of a disaster. The long-term effects of sarin should be monitored, with such investigation ideally organized and integrated by the Japanese government. Key words: sarin; disaster medicine; chemical warfare agents; emergency medical services; EMS; international medicine. ACADEMIC EMERGENCY MEDICINE 1998; 5:618-624 HE TOKYO subway sarin attack was the sec-1 ond documented incident of sarin (methyl phosphonofluoridic acid 1-methylethyl ester) nerve gas poisoning in Japan, the first episode having occurred in the city of Matsumoto in June 1994.' St. Luke's International Hospital was a major receiving hospital for the Tokyo subway sarin attack. Although St. Luke's Hospital had a disaster plan and disaster drills were carried out regularly, the disaster plan was mainly aimed at responding to fires and earthquakes. After Japan experienced the great Hanshin earthquake in January 1995, every hospital reconsidered its existing disaster plan.2 At the time of the Tokyo subway sarin attack, St.Luke's Hospital was in the process of revising its disaster planning.We have published a preliminary report on the Tokyo subway sarin a t t a~k .~ That article contained little description of the hospital resource deployment that occurred during the sarin attack disaster. In this article we address the St. Luke's Hospital disaster management response, problems encountered, and how the hospital addressed these problems. Companion articles focus oh the community emergency response4 and the national and international responses6 to this disaster.

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Six to eight months after the Tokyo subway attack in March 1995, the neurophysiological effects of acute sarin poisoning were investigated in 18 passengers exposed to sarin (sarin cases) in the subways to ascertain the focal or functional brain deficits induced by sarin. The event-related and visual evoked potentials (P300 and VEP), brainstem auditory evoked potential, and electrocardiographic R-R interval variability (CVRR), together with the score on the posttraumatic stress disorder (PTSD) checklist, were measured in the sarin cases and the same number of control subjects matched for sex and age. None of the sarin cases had any obvious clinical abnormalities at the time of testing. The P300 and VEP (P100) latencies in the sarin cases were significantly prolonged compared with the matched controls. In the sarin cases, the CVRR was significantly related to serum cholinesterase (ChE) levels determined immediately after exposure; the PTSD score was not significantly associated with any neurophysiological data despite the high PTSD score in the sarin cases. These findings suggest that asymptomatic sequelae to sarin exposure, rather than PTSD, persist in the higher and visual nervous systems beyond the turnover period of ChE; sarin may have neurotoxic actions in addition to the inhibitory action on brain ChE.