618 SARIN ATTACK Okumura et al.

TOKYO SUBWAY SARIN AWACK, PART 2

The Tokyo Subway Sarin Attack:

Disaster Management, Part 2:
Hospital Response*
TETSUOKUMURA,MD, KOUICHIROSUZUKI, MD, ATSUHIRO FUKUDA, MD,
AKITSUGU KOHAMA,MD, NOBUKATSUTAKASU, MD,
SHINICHIISHIMATSU, MD, SHIGEAKIHINOHARA,MD

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 ex-
perience include the following: Each hospital in Ja-
pan should prepare an emergent decontamination
area and have available chemical-resistant suits and
masks. Ventilation in the ED and main treatment ar-
eas should be well planned at the time a hospital is
designed. Hospital disaster planning must include
guidance in mass casualties, a n emergency staff call-
up 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 inves-
tigation ideally organized and integrated by the Jap-
anese government. Key words: sarin; disaster medi-
cine; chemical warfare agents; emergency medical
services; EMS; international medicine. ACADEMIC
EMERGENCY MEDICINE 1998; 5:618-624

HE TOKYO subway sarin attack was the sec- little description of the hospital resource deploy-
1 ond documented incident of sarin (methyl ment that occurred during the sarin attack disas-
phosphonofluoridic acid 1-methylethyl ester) nerve ter. In this article we address the St. Luke’s Hos-
gas poisoning in Japan, the first episode having pital disaster management response, problems
occurred in the city of Matsumoto in June 1994.’ encountered, and how the hospital addressed these
St. Luke’s International Hospital was a major re- problems. Companion articles focus oh the com-
ceiving hospital for the Tokyo subway sarin attack. munity emergency response4 and the national and
Although St. Luke’s Hospital had a disaster plan international responses6 to this disaster.
and disaster drills were carried out regularly, the
disaster plan was mainly aimed at responding t o
fires and earthquakes. After Japan experienced the BACKGROUND
great Hanshin earthquake in January 1995, every
hospital reconsidered its existing disaster plan.2At Prior to the sarin attack, Tokyo had disaster plan-
the time of the Tokyo subway sarin attack, St. ning, but it was mainly aimed at dealing with
Luke’s Hospital was in the process of revising its earthquakes, fires, and flood^.^ A chemical disaster
disaster planning. had never been considered, especially one involv-
We have published a preliminary report on the ing chemical warfare agents. Although the Mat-
Tokyo subway sarin a t t a ~ kThat
. ~ article contained sumoto sarin incident had increased the aware-
ness of chemical agent exposure, measures against
such agents in Tokyo, 200 km away, were poor. The
From the Department of Emergency Medicine (TO, NT, SI,
SH), St. Luke’s International Hospital, Tokyo, Japan; and the Japanese Self Defense Forces had a wide knowl-
Department of Acute Medicine (KS, AF, AK),Kawasaki Medi- edge of chemical warfare agents, but few physi-
cal School Hospital, Kurashiki-city, Okayama, Japan. Current cians in Tokyo knew anything about such agents
affiliation: Department of Acute Medicine (TO), Kawasaki before the Matsumoto sarin incident.
Medical School Hospital, Kurashiki-city, Okayama, Japan.
Received: August 15, 1997; revision received: November 5,
On the morning of March 20, 1995, 15 stations
1997; accepted: November 27, 1997; updated: December 15, of the Tokyo subway system were filled with a nox-
1997. Presented at the 10th World Congress on Emergency and ious substance later identified as a diluted form of
Disaster Medicine, Mainz, Germany, September 1997. sarin gas. A total of 5 subway commuter cars were
Address for correspondence and reprints: Tetsu Okumura, MD, affected during the Monday morning rush hour.
Department of Acute Medicine, Kawasaki Medical School Hos-
pital, 577 Matsushima, Kurashiki-city, Okayama 701-01, Ja- According t o a traffic white paper, the capacity of
pan. Fax: 81-86-463-3998; e-mail: xj2t-okmraasahi-net.or.jp subway trains between 8:OO AM and 8:40 AM
*Part 3 follows in this issue of Academic Emergency Medicine. reaches more than 200%. With such congestion,
ACADEMIC EMERGENCY MEDICINE June 1998, Volume 5, Number 6 619

passengers cannot read opened newspapers, only TABLE1. Patient Arrival during the Week aRer Exposure
magazines. The attack occurred at approximately Number of Number of
7 5 5 A.M. The terrorists carried diluted sarin solu- Date Outpatients* Admitted Patients
tion in plastic bags into the subway trains and si-
March 20 (Mon.) 640 111
multaneously stuck the sharpened tip of an um- March 21 (Tue., holiday) 116 31
brella into these bags. There were 12 fatalities, March 22 (Wed.) 319 10
and 5,500 more persons were sickened. March 23 (Thu.) 204 5
St. Luke’s International Hospital, a private 520- March 24 (Fri.) 90 3
bed facility, received the largest number of victims. March 25 (Sat.) 40 2
March 26 (Sun.) 1 2
The hospital saw 640 patients on the day of the
attack and, in total, 1,410patients in the week fol- *The number of outpatients includes only new case numbers
lowing the attack. Table 1 shows the patient vol- (initial encounters); the number of admitted patients includes
old cases.
ume on a daily basis for the first week. The hos-
pital is located within 3 km of the affected subway
stations. Figure 1 shows the location of St. Luke’sstation. Preparations were begun for burn and car-
Hospital in relationship to the affected stations. bon monoxide poisoning victims. At 8:28 A M , the
first patient complaining of eye pain and visual
ANALYSIS OF PROBLEMS darkness arrived at the ED on foot from the sub-
way station. The first ambulance arrived at 8:43
Hospital Capacity. When the first emergency AM. In the first hour, about 500 patients (including
call from the Tokyo metropolitan ambulance con- 3 patients in cardiopulmonary arrest upon arrival)
trol center of the Tokyo Metropolitan Fire Depart- were rushed to the ED.
ment came into our ED at 8:16AM, it was reported The president and vice president of St. Luke’s
that there had been a gas explosion at a subway Hospital visited the ED, saw the chaotic state it

0 AFFECTED STATIONS * St. Luke’s Int’l Hospil a1

Fiaure 1. Affected stations and St. Luke’s Hospital.

620 SARIN ATTACK
TABLE2. Secondary Exposure Symptoms in the Hospital
Workers (n = 472)
Eye symptoms 66 (14.0%)
Headache 52 (11.0%)
Throat pain 39 (8.3%)
Dyspnea 25 (5.3%)
Nausea 14 (3.0%)
Dizziness 12 (2.5%)
Nose pain 9 (1.9%)
was in, and knew the situation was extraordinary.
They initiated a disaster-oriented system and de-
clared a disaster situation when it was suspected
that hundreds of victims would soon be arriving at
the hospital. At that time all routine operations
and outpatient examinations were canceled. A con-
trol center was set up in our ED. St. Luke’s Hos-
pital has 36 residents, 129 staff doctors, 477
nurses, 68 clerks, and an average of 30 volunteers
a day. Off-duty staff members were called in, and
the staff and students of St. Luke’s College of
Nursing were mobilized.
St. Luke’s has approximately 2,000 outpatients
daily, and the day of the attack was no exception.
St. Luke’s Hospital has 3 entrances, and victims,
their families, their coworkers, television crews,
and curious onlookers could enter from any of
these doors. Therefore, the inner part of the hos-
pital was in a chaotic state. We could not block free
access because we had no definite plan for the
guidance of mass casualties. When examinations
were canceled, sufficient and repeated explana-
tions were given and we called for the understand-
ing of those at the hospital at the time. Printed
information was distributed to the victims in an
effort t o reduce their anxiety level.
Medical Charting. At first, medical charts were
filled out in the ordinary manner, but when >500
victims rushed into the hospital, we simply wrote
down each victim’s name, address, complaints,
place of work, physical findings, and treatment, re-
spectively, on a continuous sheet. Afterwards,
these continuous sheets were put between the
leaves of each patient’s ordinary medical chart.
As a result, the medical records of some of the
mildly affected patients got scattered and lost dur-
ing this chaotic period. On the day of the attack
we made a special summary sheet for admitted pa-
tients. This had a standardized format, and doctors
filled in the patient’s state of exposure (where,
when, and how he or she was exposed), signs,
symptoms, treatment, and outcome in accordance
with check boxes.
miage. At St. Luke’s Hospital, triage was done
mainly in the ED. As mentioned above, our hos-
pital has 3 entrances, and triage was done at all
Okumura et al. TOKYO SUBWAY SARIN ATTACK PART 2
these entrances. We divided victims into 3 catego-
ries: mild, ambulatory victims who presented with
only eye symptoms; moderate, nonambulatory vic-
tims who presented with other systemic signs and
symptoms; and severe, victims placed on mechan-
ical ventilation. We closely observed 528 mildly
symptomatic patients with an IV line for several
hours in the outpatient department and then sent
them home. There were 107 moderately sympto-
matic patients admitted to wards. There were 4
severely symptomatic patients admitted to our in-
tensive care unit (ICU). One severe patient was
nonreactive t o CPR and died in the ED. Overall,
triage was relatively simple and favorably done.
Fortunately, the effects of sarin on the majority of
victims were mild, and those severely affected ap-
peared at the early stage of this disaster.
Decontamination. After it became suspected
that nerve gas was the cause, we decontaminated
the admitted patients by having them change
clothes and shower. However, we were unable t o
decontaminate most mildly affected patients. This
was in part because it took time to determine the
cause of the victims’ illness and in part because we
did not have enough space for changing clothes
and showering. No room has been set aside for de-
contamination in our hospital. Victims’ clothes
were packed in plastic bags, sealed up, and kept in
the ward.
Secondary Exposure of the Hospital S t m . The
hospital staff wore gloves and masks, but only
those ordinarily used during operations and not for
the setting of chemical contamination. We had no
chemical-resistant clothing.
A study of secondary exposure of the hospital
staff was carried out by means of a questionnaire.6
The study items were sex, profession, symptoms,
and the main place of work. Basically, members of
the staff worked at one place. We sent the ques-
tionnaire to 1,063persons, of whom 472 (44%) re-
plied. Of these 472 persons working in our hospi-
tal, 110 persons (23%) complained of acute
poisoning symptoms. All 110 persons with symp-
toms were female. Table 2 shows the symptoms,
and Table 3 shows the secondary exposure per-
centages of various medical staff positions and var-
ious sites of care provision.
In St. Luke’s International Hospital there is a
chapel, in which 0,, aspiration, and compressed air
outlets were installed. Many victims were man-
aged in this area. Although this area is a useful
emergency care site, ventilation is poor. As a re-
sult, 46% of the medical staff working in this area
complained of acute poisoning symptoms. No in-
creased ventilation was provided anywhere in the
hospital during the first day. Fortunately, injury to
ACADEMIC EMERGENCY MEDICINE June 1998, Volume 5,Number 6 621

the hospital staff due to secondary sarin gas ex- TABLE3. Secondary Exposure Rates by Hospital
posure was mild. Nobody needed medical treat- Occupational Category and Site of Care Delivery
ment, although 1 nurse was admitted complaining Occupational category
of nausea, eye pain, headache, and dyspnea after Nurse assistants 39.3% (1lf28)
working in the chapel all day long. This nurse re- Nurses 26.5% (45/170)
covered in a few days. Volunteers 25.5% (14/55)
Doctors 21.8% (1W55)
Clerks 18.2% (12/66)
Antidote Storage. Initially we stored 100 am-
pules of 2-pyridine aldoxime methiodide (2-PAM) Site of care
(1 ampule contains 500 mg of 2-PAM) and 1,030 Chapel 45.8% (38183)
ICU 38.7% (12/31)
ampules of atropine sulfate (1ampule contains 0.5 Outpatient department 32.4% (34/105)
mg of atropine sulfate). While this supply permit- Ward 17.7% (14/79)
ted initial treatment of the moderate to severely ill ED 16.7% (8148)
patients, our pharmaceutical department made an
additional order to wholesale dealers at an early
stage of the disaster. According to newspapers,
9,000 ampules of 2-PAM were transported from 1 ever, their database did not include nerve agents
manufacturer to Tokyo by air. We used 700 am- at that point. The police finally identified the ma-
pules of 2-PAM and 2,800 ampules of atropine sul- terial as sarin by 11:OO AM based on mass spec-
fate. We used 1,000mg of 2-PAM initially. For the trum analysis using gas chromatograph-mass
victims whose symptoms continued, we used 500 spectrometer analysis, demonstrating that the
mghr of 2-PAM until the symptoms disappeared. agent was consistent with the spectrum of sarin as
documented in a database of the National Institute
Medical IMormation l’kansmission. We sus- of Standard and Technology (USA).
pected that the cause of the victims’ illness was In addition to the above information sources, we
some form of organophosphate agent exposure. We sought references in our own library, where MED-
were puzzled as to why it had happened in the sub- LINE and EMBASE are available. We also con-
way. The situation resembled the Matsumoto sarin tacted the Japan Poison Information Center via
incident of June 1994. telephone and facsimile regarding treatment. After
On the day of the Tokyo subway sarin attack, as much information as possible was collected, the
medical information came mainly from 3 sources. chief resident developed emergency guidelines for
Table 4 shows the time course, information, and treatment. The staff of the ED repeatedly circu-
information sources. Information came first from lated to the wards t o standardize the treatment.
the president of Shinshu University Hospital, who
had experience with treatment of the Matsumoto Follow-ups. In March 1996,we sent a question-
sarin incident victims, via telephone and facsimile. naire to the 606 victims who came to our hospital
Simultaneously, it came from a doctor sent from on the day of the attack. Table 5 shows the results
the Ground Self Defense Forces Hospital. Sponta- of this q~estionnaire.~ Of the 606 victims, 303 re-
neously, an interhospital network arose and func- plied. Of these, 46% still had some symptoms. Re-
tioned effectively. Low serum cholinesterase val- garding physical symptoms, 19% of the victims
ues, the signs and symptoms of the patients, the still complained of eye problems, 12% of easy fati-
information from the doctors who had managed gability, and 9% of headache. As for psychological
the Matsumoto sarin incident, and advice from the symptoms, 13% complained of fear of subways and
Ground Self Defense Forces Hospital led to a di- 12% indicated fears concerning their escape from
agnosis of nerve gas agent poisoning. The third the attack. A medical checkup was carried out 1
source of information was television news. It took year after the attack on 133 victims who wanted
3 hours for the police to announce officially that such a checkup.
the material was sarin, but the police did not in-
form us directly.
About 2 hours after the initial chemical expo- DISCUSSION
sure, misinformation indicating that the material
causing the victims’ illness was acetonitrile was The hospital response to this attack was particu-
provided by the Tokyo Metropolitan Fire Depart- larly concerned with management of mass chemi-
ment, but there were no findings of acetonitrile cal casualties. We were able to initiate the
poisoning (i.e., no methemoglobinemia) among the disaster-oriented system at an early phase of this
victims, so we ignored it. The Tokyo Metropolitan attack, so that our energies could be concentrated
Fire Department has hazmat teams, who based on this disaster. The canceling of all routine oper-
their diagnosis on an infrared gas analyzer; how- ations and outpatient examinations is an espe-
622 SARIN ATTACK
cially serious decision for a hospital to make. The
cooperation and understanding of patients who
were not victims made the success of this system
possible. Also, fortunately, the Tokyo subway sarin
attack occurred just after the workday began. As a
result of these circumstances, we were able to
manage this disaster relief without serious prob-
lems. We are pleased with the effectiveness of our
teamwork.
However, some problems were exposed. Prob-
lems related t o the hospital response can be di-
vided into 3 categories: 1) hardware problems
(structural problems of the hospital, including lack
of decontamination facilities); 2) software problems
(problems of disaster planning and its manage-
ment); and 3) transmission problems (communi-
cation difficulties).
The most critical problem in the first category
was the structural deficit of the hospital buildings.
Secondary exposure seemed t o have been due to
poor ventilation and the lack of a decontamination
area. Analysis of the results of the survey of sec-
ondary exposure of the hospital staff indicates that
TABLE4. Time Course of Events with Source of Information
Time Event
7 5 5 AM The attack occurred simultaneously in a
number of locations.
8:16 AM
8:25 AM First victim came to ED on foot.
8:40 AM First ambulance came.
8:43 AM First cardiopulmonary arrest patient
came by a private vehicle.
More than 500 victims were rushed
to the ED.
9:20 AM All routine operations and outpatient ex-
aminations were canceled.
9:40 AM Cholinesterase level returned: very low.
Pralidoxime was started for severe
patients.
10:30AM First press conference was given.
11:oo AM
12:OO noon Doctor conference was held to standardize
the triage and treatment.
200 PM Mildly affected patients were sent home.
5:OO PM Transportation of the admitted patients
was rejected by the Tokyo Metropolitan
Fire Department.
6 : O O PM Germany, France, and England offered the
dispatch of rescue teams.
8:OO PM Final reconfirmation of admitted
patients’ information (name, address,
severity, etc.) was done.
1o:oo PM The list of the patients was announced.
Okumura et al. TOKYO SUBWAY SARIN ATTACK, PART 2
nurse assistants and nurses had a high incidence
of secondary exposure, presumably because they
were in more direct contact with victims. Regard-
ing location, the chapel showed the highest inci-
dence of secondary exposure. It is suspected that
this was due to poor ventilation. The high inci-
dence of secondary exposure in the ICU was
thought to be due to the fact that this was where
the most severely ill patients were cared for. Un-
expectedly, the incidence of secondary exposure in
the ED was relatively low. We suspect that this
finding was due to better ventilation in the ED.
Since many victims came in succession, the en-
trance of the ED was wide open. Confirming the
condition of areas of patient management is im-
portant, and ventilation should be well planned at
the time a hospital is designed.
If sufficient field decontamination is not done,
some contaminated victims may reach hospitals by
their own means. Ideally, each hospital should
have its own decontamination facility, but such re-
modeling is expensive. As an alternative, a decon-
tamination area outside the ED entrance could be
Information Source Information
The Tokyo Metropolitan Fire Explosions occurred at subway
Department stations.
Victims There was no explosion. Many
people collapsed in the subway
station.
The Tokyo Metropolitan Fire Cause material is acetonitrile.
Department
President of Shinshu Univer- Sarin intoxication is suspected.
sity Hospital (-treatment information-)
Doctor from the Self Defense Sarin intoxication is suspected.
Forces Hospital. (-treatment information-)
TV news: police announcement Cause material is sarin.
(There was no direct infor-
mation from police.)
The Tokyo Metropolitan Fire Ambulances are not available for
Department the victims’ transport to other
hospitals until midnight.
ACADEMIC EMERGENCY MEDICINE . June 1998, Volume 5 , Number 6
created by using present parking space for an
emergent decontamination area. Respiratory pro-
tection and chemical-resistant suits with gloves
and boots are also a necessity. Hospital workers
who must care for victims of toxic chemical expo-
sure and who have not been decontaminated
should wear at least level C chemical-resistant
suits and masks (according to the U S . Environ-
mental Protection Agency definition).8Such chem-
ical-resistant suits including a mask are available
commercially.
The most serious software problem was the lack
of chemical disaster planning. The disaster plan-
ning of each hospital should include preparations
for mass chemical casualties as well as fires, floods,
and earthquakes. In a disaster situation, it is im-
portant to achieve blocking of free access to the
hospital. One systematic stream from registration
t o medical chart making t o triage to treatment is
the principle of in-hospital disaster deployment.
Furthermore, it is necessary in chemical disasters
to distinguish between victims and other people.
Fortunately, we had enough antidote storage,
which is a fundamental requirement for mass ca-
sualties from poisonings. We heard that some
other hospitals did not have it, basically because
organophosphate poisoning is rare in large cities.
In addition to drug preparedness, respirator pre-
paredness is also important in the care of nerve
agent victims. Fortunately, because the cause ma-
terial was a diluted form of sarin, the number of
victims who required a respirator was relatively
small. Had this nerve agent been used in greater
concentration, a tremendous number of victims
would have required respirators. Multiple respi-
rator systems would be needed in such a crisis.
One alternative would be t o bag-ventilate multiple
casualties during such emergencies. Securing hu-
man resources in general is essential for disaster
management. An emergency staff call-up system
for disasters is required and must be included in
hospital disaster planning.
After our experience with this attack, we be-
lieve it is necessary to have an emergency medical
chart system for disasters. Our new emergent
medical chart consists of a sheet backed with hard
paper with a neck strap and serial numbers. In
Austria, Switzerland, and Germany, casualty in-
formation tags have been introduced. Paramedics
and doctors write the various information about
victims onto triage tags with serial numbers as an
emergent chart. This system has the advantage of
including information about both out-of-hospital
care and hospital care. However, this tag system
generally implies out-of-hospital tag placement.
Until such a system is effectively implemented in
a community, each hospital should have its own
emergency medical chart system. As described
623
TABLE5. Residual Symptoms in Those Exposed Patients
Available for Follow-up after One Year (n = 303)
~~~~ ~~
Physical symptoms
Eye symptoms 56 (18.5%)
Easy fatigability 36 (11.9%)
Headache 26 (8.6%)
Dullness 22 (7.3%)
Palpitation 13 (4.3%)
Psychological symptoms
Fear of the subway 39 (12.9%)
Fear concerning escape from the attack 35 (11.6%)
Flashbacks 32 (10.6%)
Depressive feelings 24 (7.9%)
Lack of concentration 23 (7.6%)
Forgetfulness 21 (6.9%)
Nightmares 13 (4.3%)
above, on the day of the attack we created a tem-
porary admission summary sheet, which was use-
ful. Standardization of medical recording is also re-
quired.
The most significant problem in communication
was the lack of an efficient chemical disaster in-
formation network. Transmission of medical infor-
mation was especially important following this at-
tack. The police, fire departments, the Japanese
Self Defense Forces, the poison information center,
and hospitals need to form an information net-
work. The poison information center should pro-
vide general pharmacologic, pathophysiologic, and
management information systematically. All the
organizations concerned also should participate in
disaster drills. In the hospital, to avoid further con-
fusion and panic, adequate information should be
provided t o victims, families, and mass media
crews repeatedly.
Not only acute phase information but also med-
ical information during the chronic phase is im-
portant, since much is unknown about the long-
term effects of sarin in h u m a n ~ . One
~ J ~ year after
the attack, victims still complained of symptoms.
Perhaps some symptoms can be explained by post-
traumatic stress disorder. However, we believe it
is important to investigate subtle subclinical neu-
rologic changes, so we have begun to study sub-
clinical neuropsychobehavioral effects with the De-
partment of Public Health of Tokyo University."- l3
The Japanese government, however, has not yet
made any investigation of the long-term effects,
leaving this task t o each hospital. Preferably such
investigations should be organized and integrated
by the Japanese government.
CONCLUSION
We report the Tokyo subway sarin attack and how
St. Luke's Hospital dealt with this disaster from
the viewpoint of disaster management. Each hos-
624 SARIN ATTACK
pita1 should prepare an emergent decontamination
area and have available chemical-resistant suits
and masks. Ventilation in the ED and main treat-
ment areas should be well planned at the time a
hospital is designed. Hospital disaster planning
must include guidance of mass casualties, an
emergency staff call-up system, and an efficient
emergency medical chart system. Fortunately on
this occasion, the interhospital information net-
work that arose spontaneously was effective, Hos-
pitals should establish such an information net-
work during routine practice so that it can be
called upon at the time of a disaster. The long-term
effects of sarin exposure should be monitored, with
such investigation ideally organized and inte-
grated by the Japanese government.
The authors gratefully acknowledge the invaluable assistance
and support of the physicians, nurses, clerks, secretaries, and
volunteers of St. Luke's International Hospital, Tokyo. They
also thank Ilan Tur-Kaspa, MD, Chairman of the Advisory
Committee of the Israel Ministry of Health on Hospital Prep-
aration for Mass Casualty Toxicological Events, for sugges-
tions, and Paul E. Pepe, MD, Jerris R. Hedges, MD, MS, and
Mohamud Daya. MD, for critical review of the manuscript. The
authors dedicate this work to all the victims of the Tokyo sub-
way sarin attack and Matsumoto sarin incident in the name
of St. Luke.
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