Underground (34 page)

Now, phosphates have long been used in fertilizers and pesticides, and sometimes people have ingested them to commit suicide. In twenty years here I’ve treated about ten of these phosphate poisoning cases. To put it simply, sarin is phosphate in gaseous form.

MURAKAMI:
So whether one ingests an organophosphate fertilizer or sarin gas, one gets the same lowering of cholinesterase and contracted pupils?

Exactly the same symptoms. But these agricultural chemicals have up to now been liquids that don’t usually evaporate. That’s why we can spray them on roses and stuff. But since ultimately sarin is a gaseous organophosphate, doctors in Emergency Care basically know we can treat sarin poisoning cases the same way we treat organophosphate poisoning. It was only thanks to the Matsumoto incident that we discovered this.

Atropine is used in cases where the pulse is slow or as a preliminary to anesthetic, so it’s used both in emergency care and outpatient
wards in most hospitals. 2-Pam, however, is a specialized antidote to organophosphates. The pharmaceutical department might stock just a little of it.

As the gas attack was televised there was some discussion about it being either sarin or cyanide. There were interns in the lounge at the time and I told them, “Get some background on sarin.” Actually we had studied the Matsumoto incident in my university toxicology lectures. We’d put together a ten-minute videotape of TV news footage as a teaching aid, so I told them, “Look at that.” And all the interns saw what I was saying. “Now you understand about sarin. Otherwise, here are the kits in case it’s cyanide.” So we prepared ourselves and waited for the victims to come in.

Around
9:30
the TV reported that the Tokyo Fire Department had detected acetonitrile. The fire department has a special Chemical Alert Brigade car for on-site gas detection. And their report showed acetonitrile, which meant a hydrocyanide compound—cyanide.

A call came in to our hotline: “Be prepared to take a victim from the subway.” So we got ready the cyanide-poisoning kit and waited in Emergency. It was
10:45
when they brought in the patient. His pupils were contracted and he was in a fairly serious comatose state. He’d move if pinched, but otherwise there was no response. If this was cyanide, it would be what’s called acidosis: blood acidity. Acidosis indicated cyanide, but contracted pupils were an indication of sarin. That was the critical point of differentiation.

Blood tests showed no acidosis. Reflexes were way down. All symptoms of sarin poisoning. Everyone was shaking their heads: “Doctor, this just has to be sarin.” “Yes, it looks like sarin, but then the news report did say acetonitrile. Let’s try half the cyanide kit just to be on the safe side.”

About thirty minutes later there was a gradual recovery of consciousness, so we thought the cyanide kit had done the trick. His condition improved dramatically after injection. We don’t really understand why. I would guess that the perpetrators had mixed acetonitrile into the sarin in order to slow evaporation, giving them time to escape. Pure sarin would have evaporated much too quickly and in all probability killed them straightaway.

Around
11:00
the police department confirmed it was sarin. Again I found this out on TV. Did anyone think to contact us? Not a word. All our information came from TV. But by that time all the patients showed sarin-related symptoms, so we’d already begun using atropine.

About then a call came in from Shinshu University Medical Department. It was the doctor who’d treated the patients of the Matsumoto incident. He’d been calling around all the emergency care centers and hospitals in Tokyo saying, “If you want, I’ll fax you our data on sarin treatment.” “Fire away,” I said, and the faxes piled up.

Looking over the data, the most critical thing we learned was how to tell those patients who required hospitalization from those who didn’t. Without direct experience we lacked any practical basis for making a judgment. According to the data, there was no need to hospitalize patients with contracted pupils who could still walk and talk. Fine. People whose cholinesterase levels were normal did not need immediate treatment. That was helpful. If we’d had to take in everyone who came to us, we’d have been in a real fix.

MURAKAMI:
Could you
explain
briefly about cholinesterase?

If you want to move a muscle, the nerve endings send out an order to the muscle cells in the form of a chemical, acetylcholine. It’s the messenger. When the muscles receive that they move, they contract. After the contraction, the enzyme cholinesterase serves to neutralize the message sent by the acetylcholine, which prepares for the next action. Over and over again.

However when the cholinesterase runs out, the acetylcholine message remains active and the muscle stays contracted. Now muscles work by repeated contraction and expansion, so when they stay contracted we get paralysis. In the eye, that means contracted pupils.

The faxes from Matsumoto told us that a cholinesterase level of 200 or below meant the patient required hospitalization. Usually those hospitalized made a full recovery and were discharged in a few days. Unless the cholinesterase level is very low, we don’t get anything approaching paralysis. Even among our own outpatients, there were those whose readings were way down yet seemed otherwise fine. The pupil contraction persisted three or four more days, but it didn’t paralyze the breathing.

Most of the seriously injured regained consciousness within a day. The ones we couldn’t save were those whose heart or lungs had stopped before they got to the hospital. Either that, or they were infibrillated on arrival to restart their heartbeat, but became “vegetables” as a result.

MURAKAMI:
Did any remedial information come in from either the fire department or the police? With such unusual symptoms you’d think that broadcasting agreed medical guidelines from a central source would be the fastest way to reach the most people
.

No, nothing of the sort came in straight after the event. There was a bulletin from the Tokyo Bureau of Health in the early evening, around
5:00
(pulls out a file and reads):
“We greatly appreciate your looking after patients from this morning’s incident. We have obtained some sarin-related information. Sarin is a … etc., etc.” By the time this came in, we’d more or less dealt with the situation. The only ones who contacted us early on and sent us the necessary information were the Shinshu University Medical Department. That was of real practical help.

MURAKAMI:
So it was as if each medic team, each hospital was told, “You’re on your own”?

Well, yes, in effect. Knowledge about sarin was inadequate. For instance, at one hospital the doctors and nurses examining and treating the patients began to feel dizzy. Their clothes were impregnated with the gas. They became secondary casualties. Even we weren’t aware that we should have asked the patients to undress first thing. We just didn’t even think about it.

March 20, when the Tokyo gas attack happened, was in actual fact our graduation day at Shinshu University. As head of the hospital I was obliged to attend the ceremonies and had changed especially for the occasion. That day I also had an Admissions Committee meeting, so I’d scheduled absolutely nothing else. That was the stroke of luck in the midst of misfortune.

Another thing: I’d researched the Matsumoto incident and edited the findings, which were supposed to be published that day [March 20] as well. That’s how things just happened to work out.

Well, that morning, a reporter from the
Shinano Daily News
rang my secretary saying, “Something strange has happened in Tokyo. Seems kind of like the Matsumoto sarin business.” I got that message around
9:00
. “What now?” I thought, and switched on the TV and all the victims seemed to be reporting acute symptoms of organophosphorus toxicity: eye pain, tears, blurring vision, running noses, vomiting … that sort of thing. Not enough, however, to single out sarin as the cause.

But one victim among them reported a contraction of the pupils. This person came on camera saying: “When I looked in the mirror my eyes were so small.” Which all added up to organophosphorus toxicity. And since people in the subway were reporting such intense symptoms, it had to be a gas. Now, as for organophosphorus compounds used in chemical warfare, that could only mean sarin, soman, tabun, that line of compounds. The same as in Matsumoto.

By the time I had my TV on over a thousand people had been taken to St. Luke’s Hospital. I just knew the staff must be having a hell of a time, maybe even panicking. And that got me worrying.

We ourselves were really in a pinch when Matsumoto happened. Seeing all those patients coming in with unaccountable symptoms.
We’d guessed that it was probably organophosphorus intoxification and treated them accordingly; but none of us had the slightest clue it was sarin.

I immediately called in two doctors from Neuropathology and Emergency, and told them to contact St. Luke’s and any other hospitals that were thought to have taken in these patients. We faxed information to every single hospital they mentioned on TV: “Treat with sulfuric atropine and 2-Pam as antitoxin, etc., etc.”

First thing, I called St. Luke’s. This was between
9:10
and
9:30
. I couldn’t get through, but I managed to get a line straightaway on my mobile. “Get me the person in charge of Emergency,” I said, and gave a general rundown: “Do this and this and this to treat your cases.” Then I told them I’d fax in more detail. Ordinarily I ought to have cleared all this through the head of the hospital, but I thought talking directly to the doctors in the wards would be faster. But there was a mixup somewhere. I heard later from someone at St. Luke’s that they were scouring the library until 11
A.M
. trying to determine the toxin.

We started sending the faxes around 10
A.M
. I still had to attend the graduation ceremony, so I left the two doctors from Neuropathology and Emergency in charge and went. There was a final proof of the
Matsumoto Sarin Incident Report
on my desk outlining the symptoms, diagnosis, and treatment of sarin gas poisoning, so they just kept faxing out copies. I keep thinking in retrospect how lucky we were to have had that on hand. But even so, there were so many pages, so many places to send to, it took an amazing effort.

The most important thing in a mass disaster is triage: the prioritizing of patients to receive treatment. In the Tokyo gas attack, serious cases had to get first treatment, while lighter cases were left on their own to naturally get well over time. If the doctors treated everyone who came in, in the order they came in, lives may have been lost. If you don’t have a good grasp of the situation and people come in screaming, “I can’t see!” the whole scene can easily descend into a state of panic.

The doctor’s dilemma is having to decide who gets priority: the patient who can’t breathe, or the one who can’t see? Difficult judgments come with dangerous situations. It’s the hardest thing about being a doctor.

MURAKAMI
: Is there some sort of
practical manual
on what to do in a mass disaster, a guide doctors can all refer to?

No, nothing like that. Even with us, until the Matsumoto incident we had almost no idea what to do.

When I came back at noon, the phones were ringing everywhere. Requests were coming in from clinics all over the place saying, “Send us information too!” I mean, they had sarin victims in over a hunded facilities. That whole day was one big uproar. We were faxing nonstop.

If it had been an ordinary day with no graduation ceremony, I’d have been up to my neck in hospital work from
8:30
A.M
. straight through, snowed under with one thing after another. Even if someone had told me, “Something strange has happened in Tokyo,” I wouldn’t have had the time to watch anything on TV until lunchtime. We probably wouldn’t have been able to respond so quickly. It was just a very, very lucky coincidence.

Actually the most efficient thing to do would’ve been to get in touch with the fire department and let them get the word out to all these places. Well, we did try to contact the fire department, but we couldn’t get through.

The biggest lesson we learned from the Tokyo gas attack and the Matsumoto incident was that when something major strikes, the local units may be extremely swift to respond, but the overall picture is hopeless. There is no prompt and efficient system in Japan for dealing with a major catastrophe. There’s no clear-cut chain of command. It was exactly the same with the Kobe earthquake.

In. both the Matsumoto incident and the Tokyo gas attack, I think the medical organizations responded extremely well. The paramedics were also on top of things. They deserve praise. As one American expert said, to have had five thousand sarin gas victims and only twelve dead is close to a miracle. All thanks to the extraordinary efforts of the local units, because the overall emergency network was useless.

We sent faxes to at least thirty medical facilities. On the seven o’clock news the next morning they reported seventy people seriously injured. The thing about sarin poisoning is that even really serious cases can recover in a few hours if properly treated. Knowing what to do can make a huge difference.

I really thought I had to get word out, so I called the Tokyo Health Bureau, but nobody answered. It was after
8:30
by the time I got through. The person who came on the line said something like, “Well, we all have our jobs to do”—where’s the sense in that?

The fire department ought to have been quicker in getting to the scene, monitoring the whole situation, and stationing triage teams to give precise instructions. That way, the ambulance crews could respond on the spot. And probably emergency medics ought to go with them too. Active input from the medical side is vital if you want to stop people panicking.