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Friday, March 25, 2011

An Earthquake, A Tsunami, A Nuclear Disaster: Japan’s Neurologists On the Front Lines

 Japanese neurologists have seen almost none of the brain and spinal cord injuries that typically occur from the falling debris of an earthquake. In fact, the number of house and building collapses were relatively small given the size, 9.0, of the March 11 temblor, which prompted a tsunami to the north, massive aftershocks, and a potential nuclear meltdown, said one neurologist.

                In the days after the earthquake, Neurology Today reached several neurologists — all AAN members in Japan — by e-mail and, in some cases, by cell phone. All were willing to take minutes out of their 24-7 days in the clinics and hospitals at the front lines of the disaster to share their stories. One clinician, concerned about his shaky English, asked a CNN correspondent for help in translating his thoughts for this article.

                Just how bad the head and spinal injuries might have been in some of the hard-hit areas will be hard to assess, neurologists agreed. “Most [of the people who might have had these] casualties were drowned by the tsunami,” said Katsutoshi Furukawa, MD, PhD, a neurologist in the Department of Geriatrics and Gerontology at Tohoku University in Sendai. 

                The dearth of earthquake-caused injuries, in fact, produced an eerie calm at emergency clinics at first, said Nobukazu Nakasato, MD, professor of epileptology at the Tohoku University School of Medicine. “We were not so busy for the first few days because of the unique power of tsunami,” Dr. Nakasato said. “In the 24 hours after the earthquake, the disaster medical assistant team informed me that they had nothing to do because of the small number of injured people. I think less than 1 percent died from the earthquake itself.”

                In terms of neurology care, “the biggest problem has been a shortage of medicines,” Dr. Furukawa said.                 Dr. Nakasato added that many people with chronic neurological conditions such as epilepsy, multiple sclerosis, and Parkinson disease could not get needed medications due to transportation disruptions that prevented distribution of medical supplies.

                “For example, one of my patients is a housewife, 57 years old, living in Rikuzen-Takata city, which was the disaster center of the tsunami,” Dr. Nakasato said. “She became seizure free after starting lamotrigine, which was just introduced to Japan, but she lost everything, including her drugs. She has no way to access the local hospital, and even if she had access to the local hospital, the new drug is not available.”

                In another case, a 56-year-old man with intractable epilepsy was scheduled for surgery to implant a vagal nerve stimulator. “Now he is in drug deprivation status with generalized tonic chronic seizures,” Dr. Nakasato said. “Also, my colleague, a pediatric neurologist, has received two children who suffered status epilepticus two days after the tsunami.”

                Shoji Tsuji, MD, PhD, a neurologist at the University of Tokyo, said some hospitals have been nearly crippled by damage. “Hospitals damaged by the earthquake have difficulty functioning,” he said. “They lack electric power, water, food, and they are running out of supplies. Some of the doctors and medical staff members have lost family members to the tsunami. Can you imagine this?”           

                The lack of electricity is especially threatening to neurological patients who require machines to survive, said Muneshige Tobita, MD, PhD, a neurologist at the Yonezawa National Hospital. “Some of our patients who are recuperating in their homes with the help of a ventilator or other medical equipment are now in critical condition after the disasters,” he said. “With the shortage of electricity due to blackouts, and batteries running down, we recharge medical equipment using car batteries as a last resort. But here too, the gas shortage is making the situation worse.”

                There have been small improvements, however. The transportation system, which has hobbled the distribution of essential medicines and equipment, is rapidly recovering, said Shigeru Sato, MD, PhD, of the Department of Neurology at Kohnan Hospital in Sendai.

                “Highway and railway systems were partially destroyed, and we could not get gasoline,” he said. “At first, we prescribed medicine for only three to five days, and tried to share the medications. Next, the government made a temporary system so patients could get their medicines from a pharmacy near their home without a prescription. Now, lifelines have been re-established in the Sendai area, and almost all pharmacies can get enough medicine.”

                But there are other collective anxieties, owing in large part to the as yet unknown scope of the health risks related to radiation leaks from failing nuclear reactors. After 210 becquerels of radioactive iodine were detected per 1 kilogram of tap water at a water purification plant in Tokyo in late March, officials recommended that infants not drink it, according to Kyoto News. The limit is 100 becquerels for infants, 300 for adults. The Fukushima Daiichi nuclear plant is about 220 km (137 miles) northeast of Tokyo.

                Neurologists said they are increasingly concerned about an expected increase of cases of post-traumatic stress disorder (PTSD). They are hearing reports of PTSD from patients, their families, and colleagues.

                “My psychiatrist colleagues say that the PTSD is coming soon,” said Dr. Nakasato. “In fact, they told me that some of the tsunami survivors have killed themselves. Our dentist colleagues started suffering from PTSD soon after they volunteered for death certification in the tsunami area. PTSD will come when the people can go out from the shelters and see their houses. When they have to face the real tragedy of losing relatives, money loss, etc., their psychiatric needs will increase.”

                How well will neurology — and Japan – fare, given the trifecta of natural disasters? Probably better than expected, said one neurologist who has analyzed and written about other related catastrophic events. Japan is a nation extremely well prepared for earthquakes, said Farrah J. Mateen, MD, a fellow in the department of neurology at Johns Hopkins University, who wrote a 2010 article in Annals of Neurology on neurological disorders in complex humanitarian emergencies and natural disasters.”

        “Of all the literature about earthquakes and neurological problems, the majority has come out of Japan,” she said. “I think the world community can learn from Japanese neurologists and from the patients they treat.”