Day 1 (6/17/13):
Fukushima Medical University is located on a hill overlooking the city of Fukushima, roughly 60km from the Fukushima daiichi nuclear power plant that made the headlines two years ago. I’m not sure what I expected to see upon getting off the shinkansen at Fukushima station. Maybe I imagined everyone walking around with masks, or not walking around outside at all. Whatever my expectations or concerns, Fukushima turned out to be a normal small Japanese city, and its residents were not bundled in in hazmat suits or even wearing masks (at least not more than the general Japanese population). Two years after the disaster, there is a sense of normalcy here.
I arrived at Fukushima station around 7:45am on Monday morning, and took a bus to Fukushima medical University — about a half-hour ride from the station. The lectures on disaster medicine are given by Dr. Kumagai, who spearheads the educational programs for the center for disaster medicine at FMU and is an expert on the health effects of radiation exposure. He was previously at Nagasaki University, studying the effects of radiation on cancer risks in people who survived the atomic bomb in Nagasaki and Hiroshima. After the earthquake/tsunami/nuclear melt down in March 2011, he and fellow doctors from Nagasaki University relocated to Fukushima Medical University to help with relief efforts and lend their expertise.
The day started with a brief orientation, and we went over our schedule for the week: Monday and Tuesday will be mostly lectures by Dr. Kumagai; Wednesday I will participate in a hands-on disaster medicine simulation with FMU medical students; Thursday I will accompany Dr. Kumagai to Soma, one of the seaside cities, to observe community thyroid screening; Friday I will visit a health clinic in Kawamata town.
The lectures today (Monday) included an overview of the disaster at Daiichi power plant, and a basic discussion of radiation, systems of measurement, and relative risks of cancer associated with different levels of radiation exposure. I’m embarassed to admit that I barely remember basics nuclear physics that I learned just two years ago in my postbac program at Columbia… We also went outside with a radiation detector and actually measured the air dose levels of radiation in different parts of the campus.
Some of the main points from today’s lectures:
- What happened exactly to cause the nuclear melt down: the tsunami and earthquake destroyed power lines and backup power systems at Fukushima daiichi nuclear power plant. After the plant lost electricity and the cooling system stopped, the core started to heat up and melt; the reaction between the zirconium metal used in the core and the water formed H2 gas, which built up inside until the reactors exploded, releasing radioactive materials into the environment.
- The radioactive “plume” traveled over Fukushima, and came down to the ground with the rain. Because of the way the plume travelled, the air dose was actually higher in inland cities like Fukushima and Koriyama than in cities closer in distance to the power plant.
- The main fission products at Fukushima were I-131 and Cs-137. I-131 has a short half life of 8 days, while Cs-137 has a half-life of about 30 years.
- Acute reaction to radiation exposure only seems to occur if the exposure is over a certain threshold value. For acute radiation syndrome the threshold is 1 Sv (Sievert). However, chronic reactions (cancer development, etc) have a linear relationship to the radiation dosage. Effects on the fetus can be seen with in-utero exposures greater than 100 mSv.
- Sievert (Sv) is a unit indicating the health effects of radiation. Sv = energy of radiation (Gy) x weighing factors (different tissues have different constants, e.g. bone marrow is more affected than other organs and has a higher constant).
Day 2 (6/18/13):
We continued with lectures about the health effects of radiation exposure this morning. After the nuclear meltdown in 2011 there was a sort of craze to measure the amount of radiation in food and drinking water not only in Fukushima, but all over Japan. I remember reading that even sushi restaurants in New York bought radiation detectors to test all of the fish they imported from Japan, in an attempt to assuage the fears of the public. After careful study, though, the amount of radiation contained in vegetables, grains, and meats from the Fukushima area turned out to be below the safety guidelines set by the government, and far below the amount that would actually cause effects on health.
We also discussed the risks of thyroid cancer in the aftermath of the Chernobyl disaster in 1986 as well as in Fukushima. I-131, the radioactive isotope of Iodine, was one of the radioactive contaminants in both places. Since the thyroid gland actively takes up Iodine to make thyroid hormone (using this principle, I-131 is actually used to treat thyroid cancer and hyperthyroidism because Iodine is selectively taken up by thyroid cells), there were concerns that exposure to I-131 would lead to increased incidence of thyroid cancer.
In Chernobyl, the incidence of thyroid cancer actually did go up in the people who were exposed, and the greatest number of thyroid cancer cases were in the very young (0-4 year) age range. But because of the lack of information provided to the public, many people in towns near Chernobyl weren’t even aware of the nuclear meltdown, and did not evacuate, and continued to consume vegetables and dairy that were contaminated. As a result, compared to the people in Fukushima, their levels of I-131 irradiation were much much higher.
Based on the data from Chernobyl, researchers determined that the risk for thyroid cancer starts to increase after exposure of more than 100 mSv. The thyroid screening tests done on residents of (higher exposure) towns in Fukushima showed that the highest level of exposure was found to be 33mSv in adults and 23mSv in children under 18 — a stark contrast to Chernobyl, where the highest level of exposure in children was over 3000 mSv.
Still, Fukushima has been conducting thyroid screening tests to identify early cases of thyroid cancer. Unfortunately, thyroid cysts and cancers are not uncommon incidental findings — many people (irradiated or not) may have thyroid cancer without realizing it. So the more you screen, the more cases of thyroid cancer you find…when the government conducted thyroid screening in other areas of Japan from 2012-2013, they found that the percentage of people with large cysts or small nodules in their thyroid gland was actually higher than in Fukushima.
On Thursday, I will be accompanying Dr. Kumagai to Soma for thyroid screening. It should be interesting to see how people feel about the screening and their relative risks…
Day 3 (6/19/13):
The “radiation disaster medicine center” (放射線災害医療センター) is located at the end of one of the wings of Fukushima medical university hospital, past the MRI and radiation therapy rooms. The area was set up in 2001 in case of an accident at the Fukushima nuclear power plants. However, the area was apparently unused and unstocked when disaster actually struck in 2011. One side of the room has sliding doors that open directly to the outside, so that (I imagine) ambulances can rush patients who may have been exposed to radiation directly to the emergency room there without dragging them through the hospital and spreading radioactive contamination. The floor is lined with paper, and all of the medical equipment is covered in plastic in order to reduce surface contamination.
I spent the whole day today with a group of 5th year FMU medical students who are in the middle of their clinical rotation in emergency medicine. We spent the morning learning how to assess a patient in the emergency department (ED), and learned some basic maneuvers that are employed in the ED, such as intubation or putting in a chest drain. The basics of the initial assessment were the same as in the U.S: Airway, Breathing, Circulation, Disability/neurological status. We practiced on a mannequin that can simulate different respiratory rates and breathing patterns.
The afternoon was a similar setup with the mannequin, but this time we simulated a case in which the patient is an employee of the nuclear power plant, who may have been exposed to radioactive materials. We were fully equipped in protective suits, complete with a mask, cap, face shield, foot cover, two layers of gloves, and a pocket radiation monitor. Even with the air conditioner on, it was stifling.
The basics of the primary assessment of a patient who may have been exposed to radioactive materials is not really different from any other patient in the ED. However, there are added concerns about protecting the healthcare providers, equipment, and the facility from contamination–hence the protective suit/gear, the covered equipment and floor, and the isolated location of the radiation disaster medicine center. We also have to worry about what the radioactive materials were, and how much exposure there may have been. The radiation technician would first have to check for contamination with a Geiger counter before we can even appproach or examine the patient.
Our patient (the mannequin) had a wound on his leg that was contaminated with Cs-137. As we attempted to remove the contamination (apparently the best method is simply to wash with water), he started to bleed. Normally when there is hemorrhage we apply pressure to affected area — but in this case, we hesitated. Is it really safe to expose our hands (though double-gloved) to a surface that’s contaminated with radiation? What is the priority here? I think the right answer would have been to try to stop the hemorrhage as soon as possible, but the fact that we hesitated is very telling — it reflects the fear we feel about radiation exposure, the fear of the unknown. Would a medical professional (rather than the students that we were) act differently?
Day 4 (6/20/13):
I accompanied Dr. Kumagai to Soma, a tsunami-affected area of Fukushima, for thyroid cancer screening for children who were under 18 in 2011. We travelled to Soma in a chartered bus, driving through winding roads over mountains, offering me a glimpse of the deeply green and rural part of Fukushima that I hadn’t yet seen. Temporary booths were set up in a large auditorium in a community center, and the four booths were manned by Dr. Kumagai and doctors from other hospitals, from as far away as Kumamoto University Hospital in Kyushu. The screening is done with a portable ultrasound machine, and the entire exam can be as short as two or three minutes. The patients’ age ranged from about three years to twenty, and while the screening went very smoothly for teengagers, some of the smaller children resisted vehemently — one screaming child can instill fear in another, starting a chain reaction.
I observed Dr. Kumagai while he did the screening. I was surprised to find that so many children (and especially teenagers), perhaps a third of those screened, had small fluid-filled cysts in their thyroid glands. These cysts are harmless (a video droned on in the waiting area explaining the screening test and the common and benign nature of thyroid cysts), but I couldn’t help but wonder how the mothers feel, seeing a dark spot on the screen indicating a cyst in their child’s throat.
While the small cysts are harmless, thyroid nodules can be cancerous. Nodules are not quite as hypoechoic/black on ultrasound as the cysts are, and can be found alongside microcalcifications, which appear hyperechoic/white. Of the patients whom Dr. Kumagai screened today, one or two had inconclusive findings, and those patients, along with the many who had larger cysts, will be sent for secondary exams to rule out thyroid cancer.
Based on the relatively low levels of radiation that people were exposed to in Fukushima (compared to Chernobyl), it doesn’t seem likely that the incidence of thyroid cancer will increase here. But since the true incidence is not known, and widespread screening will inevitably find more cases of cysts and carcinoma than would be found otherwise, the data may look as though thyroid cancer has increased as a result of the nuclear disaster. That could further heighten people’s fear of radiation exposure, and have the unfortunate effect of keeping people away from Fukushima…
On our bus ride back, we drove through some of the tsunami-affected areas near Soma. The towns have been cleaned up fairly well, but there were some houses that had windows or entire walls missing from the ground floor, so that the dark interior of the house was visible from the outside. Along the water, all that remained of the houses were their concrete foundations, overgrown with vegetation. All of the debris had been cleaned up, so you may not even know that this area was ravaged by tsunami, if you didn’t know what had been there before.
– Yumeko Kawano
Day 5 (6/21/13):
I went to Kawamata town today for “yorozu health clinic” with Dr. Kumagai, Mr. Yasui (a nurse who is part of the center for disaster medicine), and two medical students from Mount Sinai who are conducting a research study in Fukushima this summer. Kawamata is an inland town located about an hour drive from Fukushima city. Although it was not affected directly by the tsunami, part of the town fell into the voluntary evacuation zone after the nuclear accident, and there is temporary housing set up in parts of the town. The free health screenings are conducted in various towns in Fukushima, with mobile buses equipped with X-rays and other equipment. Today it was at a health center in Kawamata, and the patients were shuttled from the waiting area inside to another room to have their blood drawn for labs, and finally to the buses parked outside for chest and abdominal X-rays. They laid out mats outside for people to sit and wait their turn for the scans. The shoes lined neatly next to the mat and outside of the buses struck me as very Japanese.
The health consultations that Dr. Kumagai offers are optional (many people choose to just have the labs and scans done and go home), so we tried to recruit patients as they were waiting to be called in and after they were done with their tests. Recruiting patients was actually much harder than we expected. A lot of people that I talked to had complaints like shoulder aches, knee pain, high blood pressure, and so on, but they did not seem particularly eager to come in for a consultation. Since they had to fast overnight, perhaps they simply wanted to go home and eat. I know that I have been unwilling in the past to go see a doctor because I didn’t feel sick enough to justify taking up someone’s time…or was afraid that I would be judged for coming in without a good enough reason. Maybe these patients felt the same way.
I was able to observe Dr. Kumagai interview two patients this morning though. The first was an elderly man (84?) who complained of pain in his butt when he walked. The second was a 71-year old woman who was concerned that she may be getting dementia because she has been forgetful recently. With both patients, there were several other complaints and issues that slowly surfaced as Dr. Kumagai conducted the interview. I learned that sometimes the chief complaint is not necessarily the most poignant or significant complaint…and if we were rushed for time (which we were not today), would we have gotten as rich and complex a story as we did?
The yorozu clinic ended at 12pm, and we headed back to Fukushima for lunch and for me to catch my train to Tokyo soon after. This has been a really intense, fulfilling, and thought-provoking week. I’m not sure yet how I can apply the knowledge that I gained this week to my future career as a doctor, but I hope I can find a way.
I would like to thank the Nishimiya fellows program, JAMSNET, JMSA, Consortium for Japan Relief, and Alisa Prager for making this trip possible; and Dr. Kumagai, Dr. Hasegawa, Mr. Yasui and the staff at the disaster medicine center at FMU, as well as FMU medical students, for sharing your expertise and extending your hospitality.
– Yumeko Kawano