[accordion] [acc_item title=”General”] Capital – Tokyo
Area – 364,485 sq km (land); 13,430 sq km (water)
Population – 126,804,433
Language(s) – Japanese

[/acc_item] [acc_item title=”Overview”]
  • ŸScoop-and-run/defibrillate
  • ŸLimited, national protocols
    • Limited scope: no medication administration (oxygen only)
  • ŸHas 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)
[/acc_item] [acc_item title=”History”]
  • ŸFirst services started by Tokyo PD pre-World War II
    • ŸIntended for trauma patients
  • Ÿ1933 – Original development of in Yokohama through local FD
    • 1935 – 6 ambulances in old Tokyo City
  • Ÿ1947 – 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)
  • Ÿ1961 – First 24h emergency service-designated hospitals assigned
  • ŸIncreased EMS services caused by two factors:
    • Increased economic viability resulted in increased car ownership (and increased vehicle collisions)
    • 1964 Olympics
  • Ÿ“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)
  • Ÿ1977 – 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)
  • ŸTwo 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
[/acc_item] [acc_item title=”EMS System Model”]
  • ŸGov’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)
  • ŸAmbulance staffing
    • 2-3 crew members
  • ŸAmbulance 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
[/acc_item] [acc_item title=”Lead Agency”]
  • ŸMinistry of Health and Welfare
[/acc_item] [acc_item title=”Funding”]
  • ŸService funded entirely by public
  • Patients do not pay out of pocket for transportation
[/acc_item] [acc_item title=”Levels of Care, Education and Training”]
  • Ÿ“In some areas, in cases of cardiac arrest, fire brigades arrive at the site to assist the ambulance “ (Tanigawa, 368)
  • ŸFirst Aid Class One (FAC-1) – 1978
    • 135h training course
      • Basic Life Support
      • Oxygen admin; Oral Airways
  • ŸStandard First Aid Class (SFAC) – 1991
    • 250h training course
      • FAC-1
      • Basic vital signs monitoring/devices
      • AED
      • Laryngoscopy for FBAO
      • PASG
      • Automatic resuscitator
  • ŸEmergency 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)
  • ŸDoctor 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)
    • Ÿ“All ambulance crews are required to be trained in firefighting techniques and ambulance vehicle operations “(Tanigawa, 368)
[/acc_item] [acc_item title=”Medical Direction”]
  • Ÿ2001 – Medical Control system developed by Committee on Upgrading Activities of Ambulance Personnel
  • Ÿ2003 – Medical Control Advisory Board established in each Japanese prefecture
  • ŸOn-line – provided via telephone or cell by base hospital/dispatch MD
  • ŸOff-line
    • Advanced – development of educational programs & protocols for prehospital providers
    • Post-Incident – Evaluation, analysis, quality control
[/acc_item] [acc_item title=”Specialty Services”]
    • 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)
  • Ÿ2004 – 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)
[/acc_item] [acc_item title=”Dispatch”]
  • Ÿ119 – 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)
[/acc_item] [acc_item title=”Emergency Medicine”]
  • Ÿ“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)
  • Ÿ1973 – Japan Association of Acute Medicine (JAAM) founded
    • Involvement was predominantly by surgeons
  • Ÿ1991 – JAAM members and others enacted Emergency Life Saving Technicians (ELST)
    • Introduction of publicly- & privately-funded Foundation for Ambulance Development
  • ŸCritical 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)
[/acc_item] [acc_item title=”Clinical Emergency Care”]
  • ŸHospital 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
[/acc_item] [acc_item title=”Disaster”]
  • Ÿ“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
  • ŸNational Disaster Information System
    • Operated by national government to provide/exchange info about impact/damage of disaster, and available hospital resources
  • Ÿ“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)
[/acc_item] [acc_item title=”References”]
  • Ÿhttps://www.cia.gov/library/publications/the-world-factbook/geos/ja.html
  • ŸLewin 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.
  • ŸO’Malley RN, O’Malley GF, Ochi G: “Emergency medicine in Japan.” Annals of Emergency Medicine 2001;38:441-6.
  • ŸTanigawa K, Tanaka K: “Emergency medical services systems in Japan: past, present, and future” Resuscitation 2006;69:365-70.
[/acc_item] [/accordion]
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