The emergency medical service system in Japan

The emergency service in Japan started with one ambulance in the fire department of Yokohama in 1933. At this point, the fire department was a part of the police service, and emergency services were only available in larger cities like Tokyo. In 1948, legislation on fire fighting and its associated organization was enacted. Since then, the fire department has become independent of the police department, and emergency services are available in major regional cities with the increasing number of traffic accidents and disasters. With the amendment of legislation in 1964, emergency services legally became a part of firefighting services (Jo SH, 2004).

The emergency medical system in Japan, unlike in the U.S., where the general population demanded the service and the government responded to the demand, was initiated by the central government and the orders were delivered downward to establish a well-structured system. Not only the demand of the general population but also the efforts of local governments

were essential for the establishment of the emergency medical system in Japan.

In 1977, a special system called the Critical Emergency Patient Transport System was initiated by the Japanese Emergency Medicine Planning Committee. The main points of the system were to distinguish primary, secondary, and tertiary emergency centers to provide patients with direct or step-wise treatments at an appropriate center. Re-building of the country after its loss in World War II, as well as natural disasters due to the geographical features of the country, have had a significant impact on the development of the emergency medical system in Japan. Therefore, the system is focused on the treatment of mass casualties from disasters and the advanced treatment of critical patients. Although it may appear that patients with mild symptoms are relatively neglected, Japan is one of the world’s top countries in terms of its emergency medical service within the areas of its focus.

Emergency medical doctors can solely focus on a very few critical patients who are transported to tertiary emergency medical center. Patients with mild symptoms can be treated at primary and secondary emergency centers as suggested by the Emergency Medical Information Center. Even though the tertiary emergency centers also have emergency rooms to treat mild patients, only critical patients or those transferred from another center for a specific treatment are given medical care within the space of the emergency center devoted to critical patient care. In other words, the patients have already been classified based on their symptoms before entering the emergency center. In Japan, emergency medical doctors require an exceptionally long training period so that they can properly treat critically ill patients until the end. They are also in charge of surgical treatment, which

makes them a combination of the American equivalents of the emergency medical doctor, traumatic injury expert, and critical care expert. These organizations are spread throughout the country and are managed by the national government. As the health insurance system is similar between Korea and Japan, the operation of tertiary emergency centers solely based on the income of the center is practically impossible; therefore, the centers receive funding from the national and/or local governments, as well as other donors.

In order to accurately yet rapidly perform the processes from the registration of the accident to transporting the patient, the Japanese emergency medical service system has established a communication system between the ambulance team and the receiving facility via wireless communication. The reporting or registration of emergency patients requiring an ambulance is done using the unified telephone number 119. The accident report is registered by the fire department, and there is no medical cost associated with ambulance dispatch.

Emergency medical information centers—mainly responsible for hospital guidance for non-emergency patients—in Japan are operated in different forms through cooperation between the local government and local medical association, and therefore there is no nationwide organization or telephone number. The fire department of Tokyo operates a separate emergency consultation center (#7119) due to the rapid increase in the number of incidents reported via 119. Consolidation of emergency telephone numbers is convenient for the reporter, but the EMD cannot easily distinguish the severity of each incident, which may result in unnecessary complications (e.g., dispatching ambulances for unnecessary cases and a consequent lack of ambulances for critical patients, or refusal to dispatch resulting in an unnecessary mortality). When patients with self-diagnosed mild symptoms

call #7119, a retired EMT or a nurse responds and provides medical consultation or hospital guidance. If needed, they can dispatch an ambulance as well.

The Emergency Life Saving Technique Attendant (ELSTA) system in Japan was established in April 1991 pursuant to Article 36 of the Emergency Life Saving Technique Attendant Act (similar to the legislation on emergency medical services in Korea). This allowed for a dramatic development in the Japanese emergency medical system. An ELSTA is defined as a person who

“is certified by the Minister of Health, Labour, and Welfare, and provides emergency life-saving treatments under physician’s medical oversight.”

The qualifications of an ELSTA include the following: ① high school graduates (or higher education) with at least two years of training at an ELSTA training center authorized by the Ministries of Education or of Health, Labour, and Welfare; ② individuals who have previously worked in the field of emergency medical service (legally specified) for a certain period of time, and have obtained necessary knowledge and technique at an ELSTA training center for at least one year; and ③ individuals with overseas certification recognized by the Ministry of Health, Labour, and Welfare. An ELSTA who graduated from a private training center to work as an ELSTA at the fire department must receive six months of basic training at a fire fighting school. ELSTAs are legally required to perform emergency medical care with detailed direction by a medical doctor, and their service should only be provided inside the ambulance or until the patient is in the ambulance.

Recently, a “Doctor Car” system has started being widely used in which an ambulance operates with either a medical doctor or a nurse (Choi DK, 2003).