The Tokyo Subway Sarin Attack: Disaster Management, Part 1: Community Emergency Response*

Abstract

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

Chemical weapon functional exercise—Cincinnati: observations and lessons learned from a “typical medium-sized” city's response to simulated terrorism utilizing weapons of mass destruction

“…15, 16 The importance of gross decontamination at the scene was highlighted during the sarin attack on the Tokyo subway system in March 1995. 19,20 Of the 1,364 first responders transporting contaminated patients to receiving hospitals, 10% became victims due to the off-gassing of the volatile sarin in the hot, poorly ventilated ambulances and Tokyo Fire Defense Agency minivans. 16,20,21 Eleven of 15 physicians caring for victims at a single local receiving hospital also reported symptoms attributable to sarin offgassing, with six requiring atropine.…”

Hospital preparedness for victims of chemical or biological terrorism

“…In the Tokyo sarin incident, one private 520-bed hospital received 640 victims in 1 day, most of whom bypassed prehospital responders and arrived without undergoing decontamination. 1,2,31 A substantial number of care providers experienced symptoms or signs of secondary exposure. 2,40 Most surveyed hospitals did not have appropriate types and sufficient numbers of respiratory protective equipment for ED staff.…”

“…Although such incidents have occurred rarely to date, the need for concern is illustrated graphically by the sarin nerve gas attack in a Tokyo subway by the Aum Shinrikyo cult in 1995, causing 11 deaths and sending thousands of people to hospitals. 1,2 The United States is not immune from terrorist attacks within its borders, as evidenced by the bombings of the World Trade Center in New York and the Murrah Federal Building in Oklahoma and by a 1984 incident in Oregon, where members of a religious commune deliberately contaminated restaurant salad bars with Salmonella typhimurium, causing 751 cases of gastroenteritis. 3 One theoretical model predicted that a terrorist attack releasing Bacillus anthracis spores in prevailing winds toward the suburb of a major city could cause up to 50000 cases of anthrax, with more than 32000 deaths, in an exposed population of 100000 people.…”

Epidemiologic clues to bioterrorism

“…1,2 The impetus for this program stemmed from a combination of high profile terrorist events in the United States, revelation of the extent of chemical and biological weapons development programs in Iraq and the former Soviet Union, and fictional and non-fictional accounts describing this threat to our civilian population. [3][4][5][6][7] Recent events, including those of September 11 and the cases of anthrax resulting from the intentional release of Bacillus anthracis, have accentuated the need for concerted efforts to counter chemical and biological terrorism. [8][9][10][11][12] The first documented deliberate use of a biological agent on a population in the United States occurred in 1984, when members of the Rajneesh sect contaminated food with Salmonella serotype typhimurium to test their ability to influence voter turnout at an upcoming election, causing illness in 751 people.…”