Japan

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General

Capital – Tokyo

Area – 364,485 sq km (land); 13,430 sq km (water)

Population – 126,804,433

Language(s) – Japanese

Prehospital Care

Overview

Scoop-and-run/defibrillate
Limited, national protocols
- Limited scope: no medication administration (oxygen only)
Has been reported that “Japanese [pre-hospital providers] and the Japanese public feel the pre-hospital scope of practice is severely limited compared with their counterparts in North America and other countries in the western hemisphere” (Lewin, 237)

History

First services started by Tokyo PD pre-World War II
- Intended for trauma patients
1933 – Original development of in Yokohama through local FD
- 1935 – 6 ambulances in old Tokyo City
1947 – Constitution of Japan established “Local Autonomy Law”, enabling local govts to provide prehospital transport services
- Remained dependant on local municipalities
- By 1991, 99.3% of population had access to prehospital services (Tanigawa, 366)
1961 – First 24h emergency service-designated hospitals assigned
Increased EMS services caused by two factors:
- Increased economic viability resulted in increased car ownership (and increased vehicle collisions)
- 1964 Olympics
“In preparation for the Tokyo Olympics in 1964 and as a result of public pressure for improved access to care, legislation was passed in 1963 to require every prefecture to establish a system of ambulance transport connected to a centralized emergency phone operator” (O’Malley, 441)
- “In 1964, the central government authorized prefectures to monetarily reward hospitals for remaining open at night” (O’Malley, 441)
1977 – Ministry of Health and Welfare successfully lobbied “to allocated an annual budge for the development of a comprehensive, organized emergency care system known as the Critical Emergency Transfer System” (O’Malley, 442)
Two recent events leading to review of Japanese EMS by public (Lewin, 238)
- Akita City
  - Pre-hospital providers were practicing ET intubation “for several years”
  - Providers were indicted, but were regarded by public as “heroes, stirring debate about their professional fates and the ‘backwardness of Japanese EMS’”
- Nov. 2002 – “tragic, sudden death of Prince Takamadonomiya at the Canadian embassy in Tokyo”
  - Defibrillation performed only with consent of base hospital physician
  - Has led to “public outcry to expand the scope of practice in Japanese EMS from its basic life-support-based system”
- 3 committees formed to address expanded scope
  - Defibrillation
  - Endotracheal Intubation
  - Drug administration

EMS System Model

Gov’t sponsored service run through Fire Departments
- Local municipal FDs are “funded for and responsible for the organization and maintenance of the emergency medical transportation system” (O’Malley, 443)
Ambulance staffing
- 2-3 crew members
Ambulance Placement (Tanigawa, 367-8)
- Regions with pop. <150,000 are provided 1 ambulance/50,000 people
- Regions with pop. >150,000 are provided 3 ambulance plus addt’l ambulance for every 70,000 people

Lead Agency

Ministry of Health and Welfare

Funding

Service funded entirely by public
- Patients do not pay out of pocket for transportation

Levels of Care & Education/Training

“In some areas, in cases of cardiac arrest, fire brigades arrive at the site to assist the ambulance “ (Tanigawa, 368)
First Aid Class One (FAC-1) – 1978
- 135h training course
  - Basic Life Support
  - Oxygen admin; Oral Airways
Standard First Aid Class (SFAC) – 1991
- 250h training course
  - FAC-1
  - Basic vital signs monitoring/devices
  - AED
  - Laryngoscopy for FBAO
  - PASG
  - Automatic resuscitator
Emergency Life-Saving Technician – 1991
- 2003 – AED w/o on-line medical control
- 2003 – Orotracheal intubation also included
  - After 262h of Additional National Standard Training Course
  - Minimum 30 successful clinical intubations
- 2006 – Epinephrine administration
  - After 220h of Additional National Standard Training Course
- No formal re-certification, though they must undergo 128h of clinical training every 2 years
  - Encouraged to participate in CEUs
- “As recently as 1990, ambulances were not equipped and paramedics not trained to assist women in labor and had been known to refuse to transport them” (O’Malley, 443)
Doctor Cars
- Modified ambulance with advanced mobile intensive care capabilities, designed to improve out-of-hospital cardiac arrest
- Staffed by Certified Emergency Specialists, young physicians training to become CES, RNs with critical care experiences, “and sometimes by paramedics” (O’Malley, 443)
- “Physicians who staff the doctor cars perform a wide and inconsistent variety of aggressive interventions at the scene of emergency situations” (O’Malley, 444)
- “All ambulance crews are required to be trained in firefighting techniques and ambulance vehicle operations “(Tanigawa, 368)

Medical Direction

2001 – Medical Control system developed by Committee on Upgrading Activities of Ambulance Personnel
2003 – Medical Control Advisory Board established in each Japanese prefecture
On-line – provided via telephone or cell by base hospital/dispatch MD
Off-line –
- Advanced – development of educational programs & protocols for prehospital providers
- Post-Incident – Evaluation, analysis, quality control

Specialty Services

HEMS
- Helicopters provided by FDs
  - Dispatched if ambulance crew determines that:
    - Ground transport delay will threaten patient’s condition/outcome
    - Environmental factors and/or road conditions will delay patient’s access to definitive care
    - Critical care physicians/equipment needed for patient during transport
“Licensed drivers are required to undergo CPR training courses at driver’s school” (Tanigawa, 369)
2004 – National law amended to allow laypersons to use AEDs
- “In 2005, at the World Expo in Aichi, five cardiac arrests with ventricular fibrillation occurred, and four of these patients resuscitated with good neurological function, by a bystander-operated AED” (Tanigawa, 369-70)

Dispatch & National Emergency Telephone #

119 – nationwide, toll-free
- Direct connection to computer-assisted emergency dispatch operator
- Dispatches nearest available ambulance
- “Well organized and very effective in rapidly deploying emergency response vehicles … despite heavy automobile traffic and pedestrian congestion” (O’Malley, 443)

Emergency Medicine & Emergency Care

“Japanese emergency medicine practitioners resemble trauma surgeons and intensive care specialists more than they do western emergency physicians” (O’Malley, 446-7)
- “The JAAM has petitioned the Ministry of Health and Welfare 4 times since 1983 to recognize emergency medicine as a unique department and specialty, but the request has been rejected each time. The opinion of the Ministry of Health and Welfare is that, because any physician is in a position to accept emergency patients, there is no need to recognize emergency medicine as a specialty and no need for hospitals to grant the emergency faculty departmental status” (O’Malley, 444)
1973 – Japan Association of Acute Medicine (JAAM) founded
- Involvement was predominantly by surgeons
1991 – JAAM members and others enacted Emergency Life Saving Technicians (ELST)
- Introduction of publicly- & privately-funded Foundation for Ambulance Development
Critical Emergency Specialist
- “A physician who has demonstrated to the JAAM an interest in acute care medicine and a proficiency in a variety of procedures” (O’Malley, 444)
- “The ‘residency’ of the CES is similar to a trauma fellowship, with some attention to the care of critically ill patients” (O’Malley, 444)

Hospital Resources Categorization

Categorization “identifies hospitals capable of handling emergency patients and enables EMS personnel to rapidly transport patients to appropriate medical facilities. … classified into three levels based on resources, administration, staff and education.” (Tanigawa, 368-9)
- Primary Emergency Facilities
  - Walk-in patients
- Secondary Emergency Facilities
  - Acute illnesses and trauma
- Tertiary Emergency Facilities (“Life-Saving Emergency Centers”)
  - Total care for critically and severely ill/traumatized
  - Responsible for medical personnel education, including ambulance personnel
  - “Advanced Life-Saving Emergency Centers” can treat severe burns, acute intoxication and reconstruction surgery for amputations

Disaster

“Two major disasters … played a major role in accelerating advancement of Japanese emergency services systems” (Tanigawa, 366)
- Hanshin-Awaji (Kobe) Earthquake (1995)
  - “taught Japanese Authority the importance of disaster preparedness in general including and effective air ambulance system” (Tanigawa, 366)
- Aum cult Tokyo Subway Sarin Attack (1995)
  - Highlighted necessity for decontamination procedures
National Disaster Information System
- Operated by national government to provide/exchange info about impact/damage of disaster, and available hospital resources
“The Ministry of Health and Welfare has begun to construct 1 disaster core hospital in each of the 47 prefectures, with additional, secondary disaster medical centers to ‘organize the disaster response’ and ‘support the local, frontline medical facilities.’” (O’Malley, 445)

References

https://www.cia.gov/library/publications/the-world-factbook/geos/ja.html
Lewin MR, Hori S, Aikawa N: “Emergency medical services in Japan: an opportunity for the rational development of pre-hospital care and research.” The Journal of Emergency Medicine 2005;28(2):237-41.
O’Malley RN, O’Malley GF, Ochi G: “Emergency medicine in Japan.” Annals of Emergency Medicine 2001;38:441-6.
Tanigawa K, Tanaka K: “Emergency medical services systems in Japan: past, present, and future” Resuscitation 2006;69:365-70.

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